Eligibility Certification Form

A person seeking medical attention who claims to be an eligible Health Net member, but who does not have a valid permanent Health Net identification (ID) card and does not appear on the most recent Eligibility Report (capitated participating physician groups (PPGs) and hospitals only), must be questioned by the PPG or provider to determine if the person is a new member or has transferred from another PPG. The PPG or provider must contact the Health Net Provider Services Center to verify eligibility, but must not delay providing or authorizing care to a Health Net member. If the patient is determined to be a new member, he or she must sign an Eligibility Certification Form before receiving services.