As a Health Plan of San Joaquin/Mountain Valley Health Plan Advantage D-SNP (HMO) member, you have access to a variety of tools and resources to help you find the information you need fast an easy. On this page you will find files such as the Privacy Practices, Evidence of Coverage, Provider Directory and much more!
Materials available on this website in PDF format may require the free Adobe Reader to view.
Download Adobe Reader for free from the Adobe website.
| Name | English | Spanish | Khmer | Vietnamese |
|---|---|---|---|---|
| Enrollment Form (Coming Soon 10/15/25) | ||||
| Disenrollment Form (Coming Soon 10/15/25) | ||||
| Appointment of Representative Form | Download | Download | Download | Download |
| Health Risk Assessment Form | Download | Download | Download | Download |
| Health Risk Assessment Form - Large Print | Download | Download | Download | Download |
| PCP Change Form (Coming Soon 01/01/26) | ||||
| Health Advance Directive Form (Coming Soon 01/01/26) | ||||
| Prior Authorization Forms (Coming Soon 01/01/26) | ||||
| Part D Model Coverage Determination Request Form (Coming Soon 01/01/26) | ||||
| Part D Model Coverage Redetermination Request Form (Coming Soon 01/01/26) | ||||
| Grievance Form (Coming Soon 01/01/26) | ||||
| Appeal Form (Coming Soon 01/01/26) | ||||
| Transportation Reimbursement Form (Coming Soon 01/01/26) |
Please click this button to view Compliance policies, including privacy and security policies that describe how we protect and maintain your personal health information.
Our plan can give you materials in languages other than English including Spanish, Cambodian, and Vietnamese, and in formats such as large print, braille, or audio. To get materials in one of these alternative formats, please call Customer Service at 1-888-361-7526 TTY 711.
All Health Plan Advantage D-SNP members who speak languages other than English can ask for help. You have the right to no-cost interpreter, as well as American Sign Language. You do not have to use a friend or children to interpret for you.
An interpreter can help you:
Need help getting an interpreter in your language? Call our Customer Service Department at
1-888-361-7526 TTY 711.
NOTE: If you want a person who speaks your language to help at your doctor’s visit, call Customer Service at least 5 (five) working days before your scheduled appointment.
7751 S. Manthey Road French Camp, CA 95231
1-888-361-7526 (TTY: 711)
Hours of Operation: 8:00 a.m. – 8:00 p.m.
Mon – Sun: October 1 – March 31
Mon – Fri: April 1 – September 30
H5734_606099_2026
Posted on August 6th, 2025 and last modified on October 1st, 2025.
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