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 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:

• 2017 California Enrollment Form - Riverside - English2017 California Enrollment Form - Riverside - English
• 2017 California Enrollment Form - San Francisco - Spanish2017 California Enrollment Form - San Francisco - Spanish
• 2017 California Enrollment Form - San Francisco - Chinese2017 California Enrollment Form - San Francisco - Chinese
• 2017 California Enrollment Form - Los Angeles - English2017 California Enrollment Form - Los Angeles - English
• 2017 California Enrollment Form - Orange - English2017 California Enrollment Form - Orange - English
• 2017 California Enrollment Form - Napa -Spanish2017 California Enrollment Form - Napa -Spanish
• 2017 California Enrollment Form - Orange - English2017 California Enrollment Form - Orange - English
• 2017 California Enrollment Form - Orange - Spanish2017 California Enrollment Form - Orange - Spanish
• 2017 California Enrollment Form - Los Angeles - English2017 California Enrollment Form - Los Angeles - English
• 2017 California Enrollment Form - Los Angeles - Spanish2017 California Enrollment Form - Los Angeles - Spanish
• 2017 California Enrollment Form - Napa - English2017 California Enrollment Form - Napa - English
• 2017 California Enrollment Form - Marin - Spanish2017 California Enrollment Form - Marin - Spanish
• 2017 California Enrollment Form - Los Angeles - English2017 California Enrollment Form - Los Angeles - English
• 2017 California Enrollment Form - Los Angeles - Spanish2017 California Enrollment Form - Los Angeles - Spanish
• 2017 California Enrollment Form - Sonoma - English2017 California Enrollment Form - Sonoma - English
• 2017 California Enrollment Form - Sonoma - Spanish2017 California Enrollment Form - Sonoma - Spanish
• 2017 California Enrollment Form - Marin - English2017 California Enrollment Form - Marin - English
• 2017 California Enrollment Form - San Bernardino - English2017 California Enrollment Form - San Bernardino - English
• 2017 California Enrollment Form - Orange - Spanish2017 California Enrollment Form - Orange - Spanish
• 2017 California Enrollment Form - Scripps Signature offered by SCAN Health Plan (HMO) - San Diego - English2017 California Enrollment Form - Scripps Signature offered by SCAN Health Plan (HMO) - San Diego - English
• 2017 California Enrollment Form - Scripps Classic offered by SCAN Health Plan (HMO) - San Diego - English2017 California Enrollment Form - Scripps Classic offered by SCAN Health Plan (HMO) - San Diego - English
• 2017 California Enrollment Form - San Bernardino - English2017 California Enrollment Form - San Bernardino - English
• 2017 California Enrollment Form - San Bernardino - Spanish2017 California Enrollment Form - San Bernardino - Spanish
• 2017 California Enrollment Form - Orange - English2017 California Enrollment Form - Orange - English
• 2017 California Enrollment Form - Scripps Classic offered by SCAN Health Plan (HMO) - San Diego - Spanish2017 California Enrollment Form - Scripps Classic offered by SCAN Health Plan (HMO) - San Diego - Spanish
• 2017 California Enrollment Form - Scripps Plus offered by SCAN Health Plan (HMO) - San Diego - Spanish2017 California Enrollment Form - Scripps Plus offered by SCAN Health Plan (HMO) - San Diego - Spanish
• 2017 California Enrollment Form - Scripps Heart First offered by SCAN Health Plan (HMO SNP)- San Diego - Spanish2017 California Enrollment Form - Scripps Heart First offered by SCAN Health Plan (HMO SNP)- San Diego - Spanish
• 2017 California Enrollment Form - Scripps Plus offered by SCAN Health Plan (HMO) - San Diego - English2017 California Enrollment Form - Scripps Plus offered by SCAN Health Plan (HMO) - San Diego - English
• 2017 California Enrollment Form - Scripps Heart First offered by SCAN Health Plan (HMO SNP)- San Diego - English2017 California Enrollment Form - Scripps Heart First offered by SCAN Health Plan (HMO SNP)- San Diego - English
• 2017 California Enrollment Form - Scripps Signature offered by SCAN Health Plan (HMO) - San Diego - Spanish2017 California Enrollment Form - Scripps Signature offered by SCAN Health Plan (HMO) - San Diego - Spanish
• 2017 California Enrollment Form - Riverside - Spanish2017 California Enrollment Form - Riverside - Spanish
• 2017 California Enrollment Form - Los Angeles - English2017 California Enrollment Form - Los Angeles - English
• 2017 California Enrollment Form - Riverside - Spanish2017 California Enrollment Form - Riverside - Spanish
• 2017 California Enrollment Form - Marin - English2017 California Enrollment Form - Marin - English
• 2017 California Enrollment Form - Marin - Spanish2017 California Enrollment Form - Marin - Spanish
• 2017 California Enrollment Form - Ventura - Spanish2017 California Enrollment Form - Ventura - Spanish
• 2017 California Enrollment Form - Los Angeles - Spanish2017 California Enrollment Form - Los Angeles - Spanish
• 2017 California Enrollment Form - San Joaquin - English2017 California Enrollment Form - San Joaquin - English
• 2017 California Enrollment Form - Riverside - English2017 California Enrollment Form - Riverside - English
• 2017 California Enrollment Form - San Bernardino - Spanish2017 California Enrollment Form - San Bernardino - Spanish
• 2017 California Enrollment Form - San Joaquin - Spanish2017 California Enrollment Form - San Joaquin - Spanish
• 2017 California Enrollment Form - San Joaquin - English2017 California Enrollment Form - San Joaquin - English
• 2017 California Enrollment Form - San Joaquin - Spanish2017 California Enrollment Form - San Joaquin - Spanish
• 2017 California Enrollment Form - Santa Clara - English2017 California Enrollment Form - Santa Clara - English
• 2017 California Enrollment Form - Santa Clara - Spanish2017 California Enrollment Form - Santa Clara - Spanish
• 2017 California Enrollment Form - Ventura - English2017 California Enrollment Form - Ventura - English
• 2017 California Enrollment Form - Los Angeles - English2017 California Enrollment Form - Los Angeles - English
• 2017 California Enrollment Form - Los Angeles - Spanish2017 California Enrollment Form - Los Angeles - Spanish
• 2017 California Enrollment Form - Riverside - English2017 California Enrollment Form - Riverside - English
• 2017 California Enrollment Form - Riverside - Spanish2017 California Enrollment Form - Riverside - Spanish
• 2017 California Enrollment Form - Sonoma - English2017 California Enrollment Form - Sonoma - English
• 2017 California Enrollment Form - San Bernardino - English2017 California Enrollment Form - San Bernardino - English
• 2017 California Enrollment Form - San Bernardino - Spanish2017 California Enrollment Form - San Bernardino - Spanish
• 2017 California Enrollment Form - Napa -Spanish2017 California Enrollment Form - Napa -Spanish
• 2017 California Enrollment Form - San Francisco - English2017 California Enrollment Form - San Francisco - English
• 2017 California Enrollment Form - Orange - English2017 California Enrollment Form - Orange - English
• 2017 California Enrollment Form - San Francisco - Spanish2017 California Enrollment Form - San Francisco - Spanish
• 2017 California Enrollment Form - Orange - Spanish2017 California Enrollment Form - Orange - Spanish
• 2017 California Enrollment Form - Los Angeles - English2017 California Enrollment Form - Los Angeles - English
• 2017 California Enrollment Form - Los Angeles - Spanish2017 California Enrollment Form - Los Angeles - Spanish
• 2017 California Enrollment Form - Napa - English2017 California Enrollment Form - Napa - English
• 2017 California Enrollment Form - San Bernardino - Spanish2017 California Enrollment Form - San Bernardino - Spanish
• 2017 California Enrollment Form - San Francisco - Chinese2017 California Enrollment Form - San Francisco - Chinese
• 2017 California Enrollment Form - San Diego - English2017 California Enrollment Form - San Diego - English
• 2017 California Enrollment Form - San Diego -Spanish2017 California Enrollment Form - San Diego -Spanish
• 2017 California Enrollment Form - Riverside - English2017 California Enrollment Form - Riverside - English
• 2017 California Enrollment Form - Riverside - Spanish2017 California Enrollment Form - Riverside - Spanish
• 2017 California Enrollment Form - Sonoma - Spanish2017 California Enrollment Form - Sonoma - Spanish
• 2017 California Enrollment Form - San Bernardino - English2017 California Enrollment Form - San Bernardino - English
• 2017 California Enrollment Form - San Bernardino - Spanish2017 California Enrollment Form - San Bernardino - Spanish
• 2017 California Enrollment Form - San Francisco - English2017 California Enrollment Form - San Francisco - English
• 2017 California Enrollment Form - Orange - Spanish2017 California Enrollment Form - Orange - Spanish
• 2017 California Enrollment Form - Riverside - English2017 California Enrollment Form - Riverside - English
• 2017 California Enrollment Form - Riverside - Spanish2017 California Enrollment Form - Riverside - Spanish
• 2017 California Enrollment Form - Los Angeles - Spanish2017 California Enrollment Form - Los Angeles - Spanish
• 2017 California Enrollment Form - San Bernardino - English2017 California Enrollment Form - San Bernardino - English
• 2017 VillageHealth Enrollment Form (HMO SNP) - Los Angeles - English2017 VillageHealth Enrollment Form (HMO SNP) - Los Angeles - English
• 2017 California Enrollment Form - Sonoma - Spanish2017 California Enrollment Form - Sonoma - Spanish
• 2017 California Enrollment Form - Marin - English2017 California Enrollment Form - Marin - English
• 2017 California Enrollment Form - Marin - Spanish2017 California Enrollment Form - Marin - Spanish
• 2017 California Enrollment Form - San Bernardino - English2017 California Enrollment Form - San Bernardino - English
• 2017 California Enrollment Form - San Bernardino - Spanish2017 California Enrollment Form - San Bernardino - Spanish
• 2017 California Enrollment Form - Sonoma - English2017 California Enrollment Form - Sonoma - English
• 2017 California Enrollment Form - Riverside - Spanish2017 California Enrollment Form - Riverside - Spanish
• 2017 California Enrollment Form - San Bernardino - English2017 California Enrollment Form - San Bernardino - English
• 2017 VillageHealth Enrollment Form (HMO-POS SNP) - Riverside - English2017 VillageHealth Enrollment Form (HMO-POS SNP) - Riverside - English
• 2017 VillageHealth Enrollment Form (HMO-POS SNP) - San Bernardino - English2017 VillageHealth Enrollment Form (HMO-POS SNP) - San Bernardino - English
• 2017 VillageHealth Enrollment Form (HMO-POS SNP) - Riverside - Spanish2017 VillageHealth Enrollment Form (HMO-POS SNP) - Riverside - Spanish
• 2017 VillageHealth Enrollment Form (HMO SNP) - Orange - English2017 VillageHealth Enrollment Form (HMO SNP) - Orange - English
• 2017 VillageHealth Enrollment Form (HMO SNP) - Los Angeles - Spanish2017 VillageHealth Enrollment Form (HMO SNP) - Los Angeles - Spanish
• 2017 VillageHealth Enrollment Form (HMO SNP) - Orange - Spanish2017 VillageHealth Enrollment Form (HMO SNP) - Orange - Spanish
• 2017 California Enrollment Form - Orange - English2017 California Enrollment Form - Orange - English
• 2017 California Enrollment Form - Orange - Spanish2017 California Enrollment Form - Orange - Spanish
• 2017 California Enrollment Form - Riverside - English2017 California Enrollment Form - Riverside - English
• 2017 VillageHealth Enrollment Form (HMO-POS SNP) - San Bernardino - Spanish2017 VillageHealth Enrollment Form (HMO-POS SNP) - San Bernardino - Spanish
• 2017 California Enrollment Form - Napa - English2017 California Enrollment Form - Napa - English
• 2017 California Enrollment Form - Napa -Spanish2017 California Enrollment Form - Napa -Spanish
• 2017 California Enrollment Form - San Bernardino - Spanish2017 California Enrollment Form - San Bernardino - Spanish
• 2017 California Enrollment Form - Los Angeles - English2017 California Enrollment Form - Los Angeles - English
• 2017 California Enrollment Form - Los Angeles - Spanish2017 California Enrollment Form - Los Angeles - Spanish
• 2017 California Enrollment Form - Riverside - English2017 California Enrollment Form - Riverside - English
• 2017 California Enrollment Form - Riverside - Spanish2017 California Enrollment Form - Riverside - 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.