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
- 2018 California Enrollment Form - Los Angeles - English
- 2018 California Enrollment Form - Los Angeles - Spanish
- 2018 California Enrollment Form - Marin - English
- 2018 California Enrollment Form - Marin - Spanish
- 2018 California Enrollment Form - Napa - English
- 2018 California Enrollment Form - Napa -Spanish
- 2018 California Enrollment Form - Orange - English
- 2018 California Enrollment Form - Orange - Spanish
- 2018 California Enrollment Form - Riverside - English
- 2018 California Enrollment Form - Riverside - Spanish
- 2018 California Enrollment Form - San Bernardino - English
- 2018 California Enrollment Form - San Bernardino - Spanish
- 2018 California Enrollment Form - San Diego - English
- 2018 California Enrollment Form - San Diego -Spanish
- 2018 California Enrollment Form - San Francisco - Chinese
- 2018 California Enrollment Form - San Francisco - English
- 2018 California Enrollment Form - San Francisco - Spanish
- 2018 California Enrollment Form - Santa Clara - English
- 2018 California Enrollment Form - Santa Clara - Spanish
- 2018 California Enrollment Form - Scripps Classic offered by SCAN Health Plan (HMO) - San Diego - English
- 2018 California Enrollment Form - Scripps Classic offered by SCAN Health Plan (HMO) - San Diego - Spanish
- 2018 California Enrollment Form - Scripps Heart First offered by SCAN Health Plan (HMO SNP)- San Diego - English
- 2018 California Enrollment Form - Scripps Heart First offered by SCAN Health Plan (HMO SNP)- San Diego - Spanish
- 2018 California Enrollment Form - Scripps Plus offered by SCAN Health Plan (HMO) - San Diego - English
- 2018 California Enrollment Form - Scripps Plus offered by SCAN Health Plan (HMO) - San Diego - Spanish
- 2018 California Enrollment Form - Scripps Signature offered by SCAN Health Plan (HMO) - San Diego - English
- 2018 California Enrollment Form - Scripps Signature offered by SCAN Health Plan (HMO) - San Diego - Spanish
- 2018 California Enrollment Form - Sonoma - English
- 2018 California Enrollment Form - Sonoma - Spanish
- 2018 California Enrollment Form - Ventura - English
- 2018 California Enrollment Form - Ventura - Spanish
- 2018 VillageHealth Enrollment Form (HMO SNP) - Los Angeles - English
- 2018 VillageHealth Enrollment Form (HMO SNP) - Los Angeles - Spanish
- 2018 VillageHealth Enrollment Form (HMO SNP) - Orange - English
- 2018 VillageHealth Enrollment Form (HMO SNP) - Orange - Spanish
- 2018 VillageHealth Enrollment Form (HMO-POS SNP) - Riverside - English
- 2018 VillageHealth Enrollment Form (HMO-POS SNP) - Riverside - Spanish
- 2018 VillageHealth Enrollment Form (HMO-POS SNP) - San Bernardino - English
- 2018 VillageHealth Enrollment Form (HMO-POS SNP) - San Bernardino - 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.
