Choose a county from the drop down list to see materials for that county.
This page helps you understand the “informing” materials you get in the mail. It also helps you choose a health plan and enroll in the Medi-Cal Managed Care HCO program.
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In-person help
- Presentation sites
We have information sessions near you. The sessions are about choosing Medi-Cal managed care plans. You can go to any session to hear about your choices and ask questions in person. Use this form to find meeting places and times for Los Angeles.
Choice enrollment forms
- Medi-Cal Managed Care Choice Enrollment Form – Medical
Use this form to join or change your medical plan. If you need help filling out the form, read How to fill out a medical form. Or call 1-800-430-4263 (TTY 1-800-430-7077). - Medi-Cal Managed Care Choice Enrollment Form – Dental
Use this form to join or change your dental plan, or to return to Regular Medi-Cal. If you need help filling out the form, read How to fill out a dental form. Or call 1-800-430-4263 (TTY 1-800-430-7077). - Cal MediConnect Choice Enrollment Form – Medical
Use this form to join or change your Cal MediConnect plan. Only use this form if you get both Medicare and Medi-Cal benefits. If you need help filling out the form, call us at 1-844-580-7272.
Exception and exemption to plan enrollment forms
- Request for medical exemption from plan enrollment
Use this form if you do not want to join a medical plan for medical reasons. It will help you ask for an exemption (release) from having to join a plan. If you need help filling out the form, call 1-800-430-4263 (TTY 1-800-430-7077). - Request for Indian Health Program non-medical exemption from plan enrollment
Only use this form if you are in an Indian Health Program. Use this form if you do not want to join a medical plan for non-medical reasons. It will help you ask for an exemption (release) from having to join a plan. If you need help filling out the form, call 1-800-430-4263 (TTY 1-800-430-7077). - Request for Coordinated Care Initiative non-medical exemption from plan enrollment
Only use this form if you are in a Coordinated Care Initiative (CCI) county and you 1) are an American Indian or 2) have been diagnosed with HIV or AIDS. Use this form if you do not want to join a medical plan for non-medical reasons. It will help you ask for an exemption (release) from having to join a plan. If you need help filling out the form, call 1-844-580-7272 (TTY 1-800-430-7077).
Medical exemption request documents
You have the right to inspect, review and get a copy of your Medical Exemption Request (MER) documents. You must be the person or the parent, guardian or personal representative of the person whose documents you want to see. To ask for your MER documents, go to one of the links below and download the fillable form you need. You can email your completed form to the Managed Care Quality & Monitoring Division, State Hearing Unit at: MCQMDStateFairHearings@dhcs.ca.gov. Or you can print the form and mail it to the address on the form.
- Individuals – Request for access to protected health information
Use this form to ask for a copy of your protected health information. If you need help filling out the form, call 1-800-430-4263 (TTY 1-800-430-7077). - Parent, guardian or personal representative – Request for access to protected health information
Use this form if you are a parent, guardian or personal representative. It will help you ask for a copy of the protected health information of the person you represent. If you need help filling out the form, call 1-800-430-4263 (TTY 1-800-430-7077).
