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.

Request for Medicare Prescription Drug Coverage Determination

Request for Redetermination of Medicare Prescription Drug Denial

Medicare Part D Prescription Drugs Claim Form

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

Learn how to appointment a representative for your 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

Disenrollment form for people with Medicare who want to join TotalCare (HMO D-SNP).

Enrollment form for people with Medicare who want to join TotalCare (HMO D-SNP).

Submit a TotalCare grievances or appeals form.

You can make a privacy request if you want to get a copy of your health information or limit how your information is shared with other organizations.

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.