Health Information Form
Provider Type
- Physicians and Practitioners
- Participating Physician Groups (PPG)
Providers can assist members in completing the Health Information Form by offering support and answering any questions they may have. Members are encouraged to complete the form within 90 days of joining the Plan, as required by the Department of Health Care Services. Completing the form is optional and all responses will remain confidential. The information provided helps determine the type of care each member may need. If a member does not already have a copy of the form, please use the appropriate form listed below.
Health Net
- Health Information Form – English (PDF)
- Health Information Form – Arab (PDF)
- Health Information Form – Armenian (PDF)
- Health Information Form – Cambodian (PDF)
- Health Information Form – Chinese simplified (PDF)
- Health Information Form – Chinese traditional (PDF)
- Health Information Form – Farsi (PDF)
- Health Information Form – Hmong (PDF)
- Health Information Form – Korean (PDF)
- Health Information Form – Russian (PDF)
- Health Information Form – Spanish (PDF)
- Health Information Form – Tagalog (PDF)
- Health Information Form – Vietnamese (PDF)