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Your new plan will use this form to make sure you get needed care.  

Complete one form for each person in your family who has enrolled in Health Plan of San Joaquin/Mountain Valley Health Plan ("Health Plan"). Filling out this form is voluntary. You will not be denied care based on your confidential answers

1. Do you need to see a doctor within the next 60 days?:
a. Have you met your doctor?
2. Do you take 3 or more prescription medicines each day?
3. Do you see a doctor regularly for a mental health condition such as depression, bipolar disorder, or schizophrenia?
4. Have you been to the emergency room two or more times in the last 12 months?
5. Have you been admitted to the hospital in the last 12 months?
6. Have you needed help with personal care, such as bathing, getting dressed or changing bandages in the last 6 months?
7. Are you using medical supplies, such as a hospital bed, wheelchair, walker, oxygen, or ostomy bags?
8. Do you have a condition that limits your activates or what you can do?
9. Are you pregnant?
If yes, are you currently seeing a doctor for this pregnancy?
10.Do you see a doctor regularly for a chronic medical condition?
If yes, fill in all that apply:

You can find your member ID on the front of your member id card.

If you think you need to see a doctor, you should go to the doctor listed on your ID card or nearby hospital.


Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. 遵守適用的聯邦民權法律規定，不因種族、膚色、民族血統、年齡、殘障或性別而歧視任何人。ATTENTION: If you speak another language, free language assistance services are available to you. Call 888.936.7526, TDD/TTY 711. 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 888.936.7526, TDD/TTY 711.


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