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
- 2023 CA SCAN Enrollment Form - English Last Modified: 10/1/2022
- 2023 CA SCAN Enrollment Form - Spanish Last Modified: 10/1/2022
- 2023 CA SCAN Enrollment Form - Chinese Last Modified: 10/1/2022
- 2023 CA SCAN Enrollment Form - Korean Last Modified: 10/1/2022
- 2023 CA SCAN Enrollment Form - Vietnamese Last Modified: 10/1/2022
- 2023 SCAN Desert Health Plan Enrollment Form - English Last Modified: 10/1/2022
- 2023 SCAN Desert Health Plan Enrollment Form - Spanish Last Modified: 10/1/2022
- 2023 Retiree Group Health Plan Enrollment Form Last Modified: 10/1/2022
- 2023 NV SCAN Enrollment Form - English Last Modified: 10/1/2022
- 2023 NV SCAN Enrollment Form - Spanish Last Modified: 10/1/2022
- 2023 TX SCAN Enrollment Form - English Last Modified: 10/1/2022
- 2023 TX SCAN Enrollment Form - Spanish Last Modified: 10/1/2022
- 2023 VillageHealth Enrollment Form - English Last Modified: 11/10/2022
- 2023 VillageHealth Enrollment Form - Spanish Last Modified: 11/10/2022
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.
