Enrollment Forms
Download the appropriate enrollment form and print the form. Then complete and sign the form and mail it to the address listed. We strongly encourage you to call us at 1-877-452-5898 (TTY Users: 711) for assistance in completing the form so your enrollment will not be delayed. You will need Adobe Acrobat Reader to view these documents.
Mail your enrollment form to:
SCAN Health PlanEnrollment Department
3800 Kilroy Airport Way, Suite 100
Long Beach, CA 90806
- 2019 SCAN Health Plans and SCRIPPS Plans Individual Enrollment Form English
- 2019 Medi-Medi Enrollment Form English
- 2019 SCAN Health Plans and SCRIPPS Plans Individual Enrollment Form Spanish
- 2019 Medi-Medi Enrollment Form Spanish
- 2019 SCAN Health Plans and SCRIPPS Plans Individual Enrollment Form Chinese
- 2019 Medi-Medi Enrollment Form Chinese
- 2019 SCAN Health Plans and SCRIPPS Plans Individual Enrollment Form Korean
- 2019 Medi-Medi Enrollment Form Korean
- 2019 VillageHealth Individual Enrollment Form English
- 2019 VillageHealth Individual Enrollment Form Spanish
- 2018 SCAN Health Plans and SCRIPPS Plans Individual Enrollment Form English
- 2018 SCAN Health Plans and SCRIPPS Plans Individual Enrollment Form Chinese
- 2018 SCAN Health Plans and SCRIPPS Plans Individual Enrollment Form Spanish
- 2018 VillageHealth Individual Enrollment Form English
- 2018 VillageHealth Individual Enrollment Form Spanish
Disclaimer
Heart First is available to anyone who has been diagnosed with Chronic or Congestive Heart Failure and/or Cardiovascular Disorders.
SCAN Balance is available to anyone who has been diagnosed with Diabetes.
SCAN Connections and SCAN Connections at Home are available to anyone who has both Medical Assistance from the State (Medicaid/Medi-Cal) and Medicare.
Medicare beneficiaries may also enroll in SCAN Health Plan through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.
