Healthcare Form
Page 1
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
Physical
When was the approximate date of last physical (Month and Year)
*
Please select...
Jan
Feb
March
April
May
June
July
August
September
October
November
December
Month
Year
I don't remember
Dental
Do you have dental insurance?
No
Yes
Name and Policy #
What was the approximate date of your Last Dental Exam? (Month and Year)
*
Please select...
Jan
Feb
March
April
May
June
July
August
September
October
November
December
Month
Year
I don't remember
Vision
Do you wear glasses or contacts?
No
Yes
Which?
Glasses
Contacts
What was the approximate date of your Last Eye Exam? (Month and Year)
*
Please select...
Jan
Feb
March
April
May
June
July
August
September
October
November
December
Month
Year
I don't remember
Medications, Allergies, etc.
Are you currently taking any medication?
Yes
No
Please list your current medications
Are you allergic to any medications?
Yes
No
Please explain
Are you allergic to anything else?
Yes
No
Please explain
Do you have any chronic or long-term illness for which you have been under medical care or take medication?
Yes
No
Please explain
General Notes/Comments
Relative or friend to contact in case of an emergency
Emergency Contact 1
Name
Phone
Relationship
Emergency Contact 2
Name
Phone
Relationship
Hidden Fields (calculated)
Physical Month Value
Dental Month Value
Vision Month Value