Individuals – Request for access to protected health information.

You can email your completed form to the Managed Care Quality & Monitoring Division, State Hearing Unit at: Or you can print the form and mail it to the address on the form. To ask for your MER documents, go to one of the links below and download the fillable form you need.

You must be the person or the parent, guardian or personal representative of the person whose documents you want to see. You have the right to inspect, review and get a copy of your Medical Exemption Request (MER) documents. If you need help filling out the form, call 1-80 (TTY 1-80). It will help you ask for an exemption (release) from having to join a plan. Use this form if you do not want to join a medical plan for non-medical reasons. Only use this form if you are in an Indian Health Program. Request for Indian Health Program non-medical exemption from plan enrollment.If you need help filling out the form, call 1-80 (TTY 1-80). Use this form if you do not want to join a medical plan for medical reasons. Request for medical exemption from plan enrollment.Or call 1-80 (TTY 1-80).Įxception and exemption to plan enrollment forms If you need help filling out the form, read How to fill out a dental form. Use this form to join or change your dental plan, or to return to Regular Medi-Cal. Medi-Cal Managed Care Choice Enrollment Form – Dental.If you need help filling out the form, read How to fill out a medical form. Use this form to join or change your medical plan. Medi-Cal Managed Care Choice Enrollment Form – Medical.Use this form to find meeting places and times for Los Angeles. You can go to any session to hear about your choices and ask questions in person. The sessions are about choosing Medi-Cal managed care plans. You can download Adobe Reader for free here. You must have the newest version of Adobe Reader to use these forms.

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