Publications and Forms
These publications and forms are for plan members. If you need a publication or form that isn’t here, contact Member Services. If you want a printed copy of any of the items here, contact Member Services.
- Member Handbook (Combined Evidence of Coverage (EOC) and Disclosure Form) (effective 2024)
- Member Handbook (Combined Evidence of Coverage (EOC) and Disclosure Form) (effective 2025)
- Health and Wellness Benefit Election Form
- Over-the-Counter (OTC) Formulary and Order Form (effective December 20, 2023)
- Authorization for Use or Disclosure of Health Information
- Complaint and Grievance Form (Formulario de quejas y reclamaciones)
- Demographic Detail Form
- Notice of Privacy Practices
- Provider Directory (effective October 1, 2024)
You can search for providers and facilities online. Go to the Network Provider and Facility Search page.
| To report any errors in the PHC California Provider Directory, please send an email to [email protected]. You may also report directory errors by calling Member Services at (800) 263-0067, Option 1 (TTY 711). Agents are available Monday through Friday, 8:00 am to 8:00 pm. |
You will need the Adobe Acrobat Reader program to view the above forms. To download this free program click here or use the link above – the link will open a new window and take you to the Adobe website.
DHCS 030716 PHC FR Form 1.0
Page Updated: October 30, 2024 @ 8:18pm