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
- 2022 CA SCAN Enrollment Form
- 2022 CA SCAN Enrollment Form - Spanish
- 2022 CA SCAN Enrollment Form - Chinese
- 2022 CA SCAN Enrollment Form - Korean
- 2022 CA SCAN Connection Enrollment Form
- 2022 SCAN Desert Health Plan Enrollment Form
- 2022 SCAN Desert Health Plan Enrollment Form - Spanish
- 2022 VillageHealth Enrollment Form
- 2022 VillageHealth Enrollment Form - Spanish
- 2022 Nevada SCAN Enrollment Form
- 2022 Nevada SCAN Enrollment Form - Spanish
- 2021 SCAN Health Plans and Scripps Plans Individual Enrollment Form English
- 2021 SCAN Health Plans and Scripps Plans Individual Enrollment Form Spanish
- 2021 SCAN Health Plans and Scripps Plans Individual Enrollment Form Chinese
- 2021 SCAN Health Plans and Scripps Plans Individual Enrollment Form Korean
- 2021 VillageHealth Individual Enrollment Form English
- 2021 VillageHealth Individual Enrollment Form Spanish
- 2021 Medi-Medi Enrollment Form English
- 2021 Medi-Medi Enrollment Form Spanish
- 2021 Medi-Medi Enrollment Form Chinese
- 2021 Medi-Medi Enrollment Form Korean
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.
