TotalCare Member Forms

For TotalCare referrals to Environmental Accessibility and Adaptability services.

For TotalCare referrals for Medically Tailored Meals (MTM) and Medically Supportive Food (MSF)

This form is for TotalCare members who may qualify for no-cost Community Supports to help with housing.

TotalCare members can fill out this form if you need at-home care with daily tasks.

Запрос на определение покрытия рецептурных препаратов Medicare

Запрос на пересмотр решения об отказе в выдаче рецептурных препаратов по программе Medicare

Форма заявления на оплату рецептурных препаратов по программе Medicare Часть D

TotalCare members can fill out this form to report potential compliance and fraud, waste and abuse concerns.

Узнайте, как назначить представителя вашей программы TotalCare HMO D-SNP

By signing this form, you give Central California Alliance for Health permission to use or disclose your protected health information for the specific purpose described below.

Choose or change your TotalCare (HMO D-SNP) primary care provider

Форма отказа от участия в программе Medicare для лиц, желающих присоединиться к программе TotalCare (HMO D-SNP).

Регистрационная форма для лиц с Medicare, желающих присоединиться к TotalCare (HMO D-SNP).

Skip to content Find a Doctor Nurse Line Provider Portal Contact Us aA Accessibility ToolsGrayscaleAAA Search Search Health Plans Medi-CalMedi-Cal is California’s Medicaid health care program that provides no-cost or low-cost health insurance to Californians. Alliance TotalCare (HMO D-SNP)The Alliance’s TotalCare HMO D-SNP is a special type of Medicare Advantage plan that is available to…

Узнайте, как раскрыть информацию о вашей программе TotalCare HMO D-SNP

Вы можете сделать запрос на конфиденциальность, если хотите получить копию своей медицинской информации или ограничить передачу вашей информации другим организациям.

Learn how to replace your TotalCare (HMO D-SNP) member ID card

Use this form to ask TotalCare to send your confidential or sensitive health information to a different address, phone number, or email.

The TotalCare will acknowledge receipt of your complaint or appeal in writing within five (5) calendar days, and respond to your complaint or appeal in writing within thirty (30) calendar days.

TotalCare members can use this form to sign up for health programs. Please allow 10 business days for us to process your request.

Fill out the TotalCare Member Reimbursement Claim Form to ask for reimbursement for covered services. If you have any questions or need assistance with this form, please call our Member Services department at 833-530-9015.

Please fill out the Records Access Request Form to obtain a copy of your TotalCare medical records.

If you have changes to your address or phone number, you will need to contact both TotalCare and your county’s Medi-Cal office to update your contact information. Fill out this form to update your address and/or phone number with TotalCare.