Collecting Insurance Cards
Contact ID
RS Year
File Owner ID
First Name
Last Name
Date of Birth
Medi-Cal
See below for examples of what your Medi-Cal ID may look like. Please provide the ID number from your card as indicated in the image.
Old Design
New Design
Do you have Medi-Cal?
No
Yes
ID #
Please upload an image of the
front
of the card
I don't have a Medi-Cal card
Which insurance manages your Medi-Cal benefits?
Please select...
Alameda Alliance
Anthem Blue Cross
Anthem Blue Cross PSHP
CalOptima
CCAH Central California Alliance f. Health
CCHP
CenCal Health
Health Net
HPSM
Inland Empire Health Plan
Kaiser
L.A. Care Health Plan
Molina Healthcare
PSHP
PSHP Marin
PSHP Solano
PSHP Sonoma
PSPH Yolo
SCFHP
SFHP
Other
Name and ID#
What is the name of the other insurance?
ID #
Please upload
an image of the
front
of the card
I don't have an insurance card
Other Insurance
Do you have any other insurance through someone's employment (HMO, PPO or Kaiser)?
No
Yes
Name of Insurance
ID #
Please upload an image of the
front
of the card
I don't have a card
School Insurance
Only if you are attending a private school or UC and have received a grant
or
did
not waive the school insurance
School Insurance
School Insurance ID
Please upload an image of the
front and back
of the card
General Notes/Comments