HPSJ Member Forms

Form Fill out

This Member Forms page is where you can access different requests, disclosures and authorizations. These forms can assist you with how to request copies of documents or materials, authorize someone else to speak on your behalf, and request Health Plan of San Joaquin services. Please note that forms cannot be completed online. You will need to print out the form(s), complete all sections, and mail or fax back to Health Plan of San Joaquin.

Mail:
Health Plan of San Joaquin
ATTN: Customer Service
7751 S. Manthey Road
French Camp, CA 95231

Fax: (209) 461-2550

HIPAA Forms

Authorization for the Use and Disclosure of Health Information

This form will allow adult members to give access to any other person to speak/act in their behalf with Health Plan of San Joaquin staff. This form may also be used by parents who would like to grant access to another individual to speak/act in behalf of their own minor member/child.

Note: To request this form in a different language, please contact Customer Service at (209) 942-6320

Caregiver Affidavit

This form allows family members access to speak/act in in behalf of a minor member with Health Plan of San Joaquin staff in the absence of parents and/or legal guardians in the absence of legal court issued documents including guardianship letters.

Family members are: spouse, parent, stepparent, brother, sister, stepbrother, stepsister, half-brother, half-sister, uncle, aunt, niece, nephew, first cousin, or any person with a prefix of “grand” or “great”, or the spouse of any of the family members listed above.

Note: To request this form in a different language, please contact Customer Service at (209) 942-6320

Request to Access Health Information

This form will allow members to request access to their own member health records or materials from Health Plan of San Joaquin for personal viewing or to be shared with someone else on their behalf. Information that may be requested includes enrollment, payment, claims, and medical or case management records.

Note: To request this form in a different language, please contact Customer Service at (209) 942-6320

Posted on August 2nd, 2021 and last modified on November 5th, 2021.

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