On Feb. 21, 2024, Change Healthcare experienced a cyber security incident. Any individuals impacted by this incident will receive a letter in the mail. Learn more about this from Change Healthcare, or reach out to the contact center at 1-866-262-5342.
Member Forms | CA Healthnet
Additional Forms
Use this form when you want to allow us to share your health information with a person or group:
- PHI Authorization Form - English (PDF)
- PHI Authorization Form - Spanish (PDF)
- PHI Authorization Form - Chinese (PDF)
Use this form when you want us to cancel or revoke your previous permission to share health information with a person or group:
- PCP Change Request Form - English (PDF)
- PCP Change Request Form - Spanish (PDF)
- PCP Change Request Form - Chinese (PDF)
- PCP Change Request Form - Korean (PDF)
- PCP Change Request Form - Vietnamese (PDF)
- PCP Change Request Form - Tagalog (PDF)
- PCP Change Request Form - Arabian (PDF)
- PCP Change Request Form - Armenian (PDF)
- PCP Change Request Form - Cambodian (PDF)
- PCP Change Request Form - Farsi (PDF)
- PCP Change Request Form - Russian (PDF)
If you have questions please, contact Member Services.