Member Forms and Brochures

• Medical Claim Form for Group and Individual & Family Plans - English (PDF)
• Medical Claim Form for Group and Individual & Family Plans - En Español (Spanish) (PDF)

Complete the claim form for each member submitting bills for reimbursement of covered services. To avoid any delay, be sure to answer each question completely. PLEASE ATTACH FULLY ITEMIZED BILLS AND PROOF OF PAYMENT.

Proof of payment includes:

• Copy of cancelled check (front and back) or online bank statement
• Copy of credit card statement or bank statement

NOTE:

• Proof of payment on a Dr.'s prescription form is not acceptable.
• Invoices are not acceptable forms of proof of payment.

• Medicare - Medical - MHN Claim Form & Foreign Claim Questionnaire - English (PDF)
• Non-Medicare – Behavioral Health (MHN) - Claim Form - English (PDF)
• IFP and Group Member Grievance Form - English (PDF)
• IFP and Group Member Grievance Form - Chinese (PDF)
• IFP and Group Member Grievance Form - En Español (Spanish) (PDF)

Please explain in detail the circumstances that led to your dissatisfaction with Health Net. Please include the original copy of any claims or bills received which are related to your issue.

• Dental Claim Form - English (PDF)
• Medicare Supplement Plan Claims
• Out-of-Network Vision Claim Form (non-Medicare) - English (PDF)

• Foreign Claims Questionnaire - English (PDF)
• Foreign Claims Questionnaire - En Español (Spanish) (PDF)

For Healthy Families, Healthy Kids and AIM plan members. Medi-Cal members please contact Member Services.

• Small Group Enrollment/Change Form - English (PDF)
• Small Group Enrollment/Change Form - En Español (Spanish) (PDF)
• Small Group Enrollment/Change Form - Chinese (PDF)
• Small Group Enrollment/Change Form - Korean (PDF)
• Small Group Enrollment/Change Form - Vietnamese (PDF)
• Large Group Enrollment/Change Form - English (PDF)
• Large Group Enrollment/Change Form - En Español (Spanish) (PDF)
• Large Group Enrollment/Change Form - Chinese (PDF)
• Large Group Enrollment/Change Form - Korean (PDF)
• Large Group Enrollment/Change Form - Vietnamese (PDF)
• Health Net Life Group Employee/Dependent Enrollment Form - English (PDF)
• Health Net Life Group Employee/Dependent Enrollment Form - En Español (Spanish) (PDF)
• Health Net Life Group Employee/Dependent Enrollment Form - Chinese (PDF)
• HSA for Life - Enrollment Packet - English (PDF)
  For enrolling in a Health Savings Account (HSA)
• Hardship Exemption Form - English (PDF)

Pre-enrollment Material

• Welcome Letter – English (PDF)
• Choice Form Flyer – English (PDF)

Post-enrollment Material

• Welcome Letter – English (PDF)
• Welcome Booklet – English (PDF)
• Health Information Form Flyer – English (PDF)
• Health Information Form Flyer – En Español (Spanish) (PDF)
• How To Get Care – English (PDF)
• Telehealth Flyer – English (PDF)
• Preventive Care Services (ACA Non-Grandfathered Plans) – English (PDF)
• Preventive Care Services (ACA Non-Grandfathered Plans) – En Español (Spanish) (PDF)
• Healthy Smiles – English (PDF)
• Health Education Services Flyer – English (PDF)
• Community Resource Center Flyer – English (PDF)

First Health Provider Nomination Form – English (PDF)

You can save a lot by using a doctor who participates in the First Health Network. That's why we make it easy for you to nominate him or her to join.

• Continuity of Care Assistance Request Form – English (PDF)
• Continuity of Care Assistance Request Form – En Español (Spanish) (PDF)
• Disabled Dependent Certification Form – English (PDF)
• Out-of-Pocket Maximum Notification – English (PDF)
• Non-Discrimination Notice/Taglines Flyer – English (PDF)
• Directory Flyer – English (PDF)
• 2019 – Seniority Plus Overview Brochure – English (PDF)
• 2019 – Part C and Part D Star Ratings – English (PDF)
• Healthy Discounts Brochure – English (PDF)
• Medicare Claim Form – English (PDF)

Mail Order Pharmacy

• CVS Caremark Mail Order Pharmacy - English (PDF)
• CVS Caremark Mail Order Pharmacy - En Español (Spanish) (PDF)

Medication Therapy Management

Personal Medication List - English (PDF)

Prescription Claims

• Prescription Drug Claim Form (Medicare Members) - English (PDF)
• Prescription Drug Claim Form (Medicare Members) - En Español (Spanish) (PDF)
• Prescription Drug Claim Form (Commercial Members) - English (PDF)
• Prescription Drug Claim Form (Commercial Members) - En Español (Spanish) (PDF)

Prescription Transition Form

• Prescription Transition Form (Commercial Members) - English (PDF)
• Prescription Transition Form (Commercial Members) - En Español (Spanish) (PDF)

• Authorization For Disclosure of PHI - English (PDF)
• Authorization For Disclosure of PHI - En Español (Spanish) (PDF)
• Authorization For Disclosure of PHI - Chinese (PDF)
• Authorization For Disclosure of PHI - Korean (PDF)

• Authorization For Use or Disclosure of Medical Information - English (PDF)
• Authorization For Use or Disclosure of Medical Information - En Español (Spanish) (PDF)
• Authorization For Use or Disclosure of Medical Information - Arabic (PDF)
• Authorization For Use or Disclosure of Medical Information - Armenian (PDF)
• Authorization For Use or Disclosure of Medical Information - Cambodian (PDF)
• Authorization For Use or Disclosure of Medical Information - Chinese (PDF)
• Authorization For Use or Disclosure of Medical Information - Farsi (PDF)
• Authorization For Use or Disclosure of Medical Information - Hmong (PDF)
• Authorization For Use or Disclosure of Medical Information - Korean (PDF)
• Authorization For Use or Disclosure of Medical Information - Russian (PDF)
• Authorization For Use or Disclosure of Medical Information - Tagalog (PDF)
• Authorization For Use or Disclosure of Medical Information - Vietnamese (PDF)

HIPAA authorization forms required for requesting applicant and member medical records.

• Medi-Cal - GRIEVANCE FORM
• Medi-Cal Dental - GRIEVANCE FORM

• Continuity of Care - English (PDF)
• Continuity of Care - Arabic (PDF)
• Continuity of Care - Armenian (PDF)
• Continuity of Care - Cambodian (PDF)
• Continuity of Care - Chinese (PDF)
• Continuity of Care - Hmong (PDF)
• Continuity of Care - Farsi (PDF)
• Continuity of Care - Korean (PDF)
• Continuity of Care - Russian (PDF)
• Continuity of Care - En Español (Spanish) (PDF)
• Continuity of Care - Tagalog (PDF)
• Continuity of Care - Vietnamese (PDF)

• Glossary of Health Coverage and Medical Terms - English (PDF)
• Glossary of Health Coverage and Medical Terms - En Español (Spanish) (PDF)
• Glossary of Health Coverage and Medical Terms - Chinese (PDF)
• Glossary of Health Coverage and Medical Terms - Navajo (PDF)
• Glossary of Health Coverage and Medical Terms - Korean (PDF)

Health insurance companies and group health plans are required to make available a uniform glossary of health coverage and medical terms commonly used in plan documents. The Uniform Glossary is meant to help the consumer understand some of the most common language used in health insurance documents. Please log in to request a hardcopy of the document by mail.