Individual and Family Plan
Enrollment Application Form - On Exchange

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Tel: 1-888-371-3060 | Fax: 1-415-955-8819

Chinese Community Health Plan (CCHP) will provide translation or other language assistance free of charge incompleting the application. The application, together with the Disclosure Form/Evidence of Coverage (“Agreement”) constitutes the plan contract, and that applicants may request a copy of the Agreement prior to enrollment to learn the terms and conditions of the plan contract.

Proposed Effective Date
(MM/DD/YY) ____ /01/________
Reason for Application
IF Signing Up for a New Plan
  • Open Enrollment (Nov 1st - January 31st)
  • Special Enrollment (February 1st - October 31st)
IF Adding Dependent(s) to an Existing Plan
  • Adding Spouse / Domestic Partner
  • Adding Child(ren)
Current Member ID
Current Plan
Please Select a Plan
Medical Plans
Speak with your employer before selecting your medical plan. Not all options may be available to you.
    Optional Riders
      Note(s) (CCHP Use Only)
      1. Members to be Added to Plan
      Primary Applicant
      Prefix
      First Name
      MI
      Last Name
      Suffix
      Date of Birth (MM/DD/YY)
      Marital Status
      SSN
      Email
      Cell Phone
      Home Phone
      Home Address (No P.O. Box)
      City
      State
      Zip
      Mailing Address (if different from above)
      City
      State
      Zip
      Race (check all that apply)
        Ethnicity (Check all that apply)
          Preferred Language for Health Care
          • WRITTEN SPOKEN
          • WRITTEN SPOKEN
          • WRITTEN SPOKEN
            Assigned Sex at Birth
              Current Gender Identity
                Sexual Orientation
                  PCP Information
                  Primary Care Physician (PCP)
                  Medical Group
                  Current patient of this PCP?
                  • Yes
                  • No
                  • Spouse
                  • Domestic Partner
                  Prefix
                  First Name
                  MI
                  Last Name
                  Suffix
                  Date of Birth (MM/DD/YY)
                  Marital Status
                  SSN
                  Email
                  Cell Phone
                  Home Phone
                  Race (check all that apply)
                    Ethnicity (Check all that apply)
                      Preferred Language for Health Care
                      • WRITTEN SPOKEN
                      • WRITTEN SPOKEN
                      • WRITTEN SPOKEN
                        Assigned Sex at Birth
                          Current Gender Identity?
                            Sexual Orientation
                              PCP Information
                              Primary Care Physician (PCP)
                              Medical Group
                              Current patient of this PCP?
                              • Yes
                              • No
                              Dependent #1
                              Prefix
                              First Name
                              MI
                              Last Name
                              Suffix
                              Date of Birth (MM/DD/YY)
                              Marital Status
                              SSN
                              Email
                              Cell Phone
                              Home Phone
                              Race (check all that apply)
                                Ethnicity (Check all that apply)
                                  Preferred Language for Health Care
                                  • WRITTEN SPOKEN
                                  • WRITTEN SPOKEN
                                  • WRITTEN SPOKEN
                                    Assigned Sex at Birth
                                      Current Gender Identity
                                        Sexual Orientation
                                          PCP Information
                                          Primary Care Physician (PCP)
                                          Medical Group
                                          Current patient of this PCP?
                                          • Yes
                                          • No
                                          Dependent #2
                                          Prefix
                                          First Name
                                          MI
                                          Last Name
                                          Suffix
                                          Date of Birth (MM/DD/YY)
                                          Marital Status
                                          SSN
                                          Email
                                          Cell Phone
                                          Home Phone
                                          Race (check all that apply)
                                            Ethnicity (Check all that apply)
                                              Preferred Language for Health Care
                                              • WRITTEN SPOKEN
                                              • WRITTEN SPOKEN
                                              • WRITTEN SPOKEN
                                                Assigned Sex at Birth
                                                  Current Gender Identity
                                                    Sexual Orientation
                                                      PCP Information
                                                      Primary Care Physician (PCP)
                                                      Medical Group
                                                      Current patient of this PCP?
                                                      • Yes
                                                      • No
                                                      3. Is any person applying for coverage currently enrolled with Medicare?
                                                      • No
                                                      • Yes (please attach a copy of your Medicare card(s) & Name)
                                                      4. Disclosure of Personal and Health Information
                                                      CCHP understand the importance of keeping your and your dependents’ personal and health information private. CCHP protects this information in electronic, written, and oral forms when used throughout our company. CCHP will not disclose this information without your authorization except as permitted by law. For the purpose of administering your CCHP coverage, CCHP is permitted by state and federal law to obtain your and your dependents’ health information from a healthcare provider, insurer, insurance support organization, health plan, or your insurance agent. Also, by state and federal law, CCHP is permitted to disclose your and your dependents’ health information to a healthcare provider, insurer, insurance support organization, health plan, or your insurance agent. A complete explanation of CCHP policies and procedures (“Notice of Confidentiality and Privacy Practices”) for preserving the confidentiality of your personal and health information is available and will be furnished to you upon request by calling the Customer Service Department or by accessing CCHP’s website.
                                                      5. Arbitration Agreement
                                                      I understand that (except for Small Claims cases) any and all disputes, including claims of medical malpractice (that is as to whether any medical services rendered under the health plan were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), which may arise under the agreement between me and CCHP and any of this affiliates shall be determined by submission to binding arbitration as provided by California law. Any such dispute will not be resolved by a lawsuit or resort to court process except as applicable law provides for judicial review of arbitration proceedings. ALL PARTIES TO THIS CONTRACT, BY ENTERING INTO IT, ARE GIVING UP THEIR CONSTITUTIONAL RIGHT TO HAVE ANY SUCH DISPUTE DECIDED IN A COURT OF LAW BEFORE A JURY, AND INSTEAD ARE ACCEPTING THE USE OF BINDING ARBITRATION. For more information regarding binding arbitration, please refer to your Evidence of Coverage.
                                                      Applicant Signature
                                                      Print Name
                                                      Date (MM/DD/YY)
                                                      Spouse / Domestic Partner Signature
                                                      Print Name
                                                      Date (MM/DD/YY)
                                                      Confidentiality of Data Collected

                                                      Chinese Community Health Plan (CCHP) is required to comply with various State and Federal laws to protect, secure, retain, and maintain confidentiality of your sensitive and personal information. These laws include, but not limited to, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Health Infor-mation Technology for Economic and Clinical Act (HITECH), the Centers for Medicare and Medicaid Services (CMS), and the California Consumer Privacy Act (CCPA). CCHP has put in place policies and procedures to ensure that access to or use of your personal information is secure. Policies and processes include, but not limited to, the following:

                                                      Data Protection Policies include, but not limited to, the following:

                                                      1. Safeguarding and Use of Personal Health and Personally Identifiable Information.
                                                      2. Clean Desk Policy.
                                                      3. Records Management (How Long Do We Keep or Retain Members’ Records).
                                                      4. Member Authorization and Access to Medical Information and Records.
                                                      5. Member Rights to Request Restrictions on Use and Disclosure of Personal Health and Personally Identifiable Information.
                                                      6. Member Request to Amend Medical Record and/or Personal Health and Personally Identifiable Information.

                                                      Additional
                                                      Dependent(s)

                                                      Balance by CCHP Logo

                                                      Dependent Information
                                                      Prefix
                                                      First Name
                                                      MI
                                                      Last Name
                                                      Suffix
                                                      Date of Birth (MM/DD/YY)
                                                      Marital Status
                                                      SSN
                                                      Email
                                                      Cell Phone
                                                      Home Phone
                                                      Race (check all that apply)
                                                        Ethnicity (Check all that apply)
                                                          Preferred Language for Health Care
                                                          • WRITTEN SPOKEN
                                                          • WRITTEN SPOKEN
                                                          • WRITTEN SPOKEN
                                                            Assigned Sex at Birth
                                                              Current Gender Identity
                                                                Sexual Orientation
                                                                  PCP Information
                                                                  Primary Care Physician (PCP)
                                                                  Medical Group
                                                                  Current patient of this PCP?
                                                                  • Yes
                                                                  • No