Health Net Redetermination Form



MEDICARE PR G RAMS

Medicare

Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) Medicare 60

Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) Attention: Medicare Pharmacy Appeals P.O. Box 31383 Tampa, FL 33631-3383

1-866-388-1766

mmp. 1-855-464-3571 (Los Angeles County) or 1-855-464-3572 (San Diego County)711 8 8

H3237_19_RedetermForm2_Accepted_07182019 (CHI)

ID

CMS-1696

1-800-Medicare (1-800-633-4227)TTY: 1-877-486-2048 7 24

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7 7 72

72

Medicare /

 ____________________________________ ___________________

Health Net Community Solutions, Inc. Medicare Medi-Cal

LANGUAGE ASSISTANCE ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call 1-855-464-3571 in Los Angeles County or 1-855-464-3572 in San Diego County (TTY: 711) from 8:00 a.m. to 8:00 p.m, Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free.

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