Forms for Members
FIND A DOCUMENT OR FORM
|Continuity of Care Form
In certain circumstances (see Request Form), you may temporarily continue with a physician who is not part of the Western Health Advantage (WHA) practitioner network, or if you are a new member who has been receiving care from a Non-Participating Provider, you may continue care with that provider if you meet the continuity of care requirements listed on the Request Form.
|Declaration of Disability For Over Age Dependents.
This form is required for a dependent child who would normally lose their eligibility under WHA solely because of age, but is eligible for disabled status because he/she is chiefly dependent upon the subscriber for support and is incapable of self-sustaining employment by reason of a physically or mentally disabling injury, illness or condition incurred prior to age 19. Mail the completed form to Western Health Advantage, 2349 Gateway Oaks Drive, Suite 100, Sacramento, CA 95833.
Disease Management Form.
You may self enroll into WHA's Disease Management programs for any of the chronic conditions listed below by completing the online Disease Management Referral Form. Completed forms should be mailed or faxed to Western Health Advantage, Attention: Health Promotion and Disease Management Department, 2349 Gateway Oaks Drive, Suite 100, Sacramento, CA 95833; Fax: (916)568-0278:
If you have a complaint or grievance with WHA or a WHA provider, you may use this form to begin the grievance process by mailing the completed form to Western Health Advantage, Attention: Grievances & Appeals, 2349 Gateway Oaks Drive, Suite 100, Sacramento, CA 95833 or faxing it to (916)563-2207.
|Incentive Form: Diabetic Retinal Eye Exams
Diabetic Retinal Eye Exams (DRE) Incentive Form
*Limited to one per year.
|Incentive Form: Breast Cancer Screening
Breast Cancer Screening (BCS) Incentive Form
*Limited to one per year.
|Privacy Complaint Form
As required by the Health Information Portability and Accountability Act (HIPAA) of 1996, you have a right to voice complaint(s) about our privacy policies, procedures or actions. You may begin the complaint process by mailing the completed form to Western Health Advantage, Attention: Grievances & Appeals, 2349 Gateway Oaks Drive, Suite 100, Sacramento, CA 95833 or faxing it to (916)563-2207.
|Rate Filing Disclosure
WHA supplies this rate information pursuant to California Health and Safety Code section 1385.07(d).
|HMO Help Center Complaint Form
You may complete and forward this form to the Department of Managed Health Care (DMHC), if you filed a complaint or grievance with your health plan. Mail or fax this form and any attachments to HMO Help Center, Department of Managed Health Care, Complaint Unit, 980 9th St., Suite 500, Sacramento, CA 95814; Fax: (916)255-5241.
If you have lost your group health benefits with WHA, you may be eligible to continue your
health benefits by enrolling in WHA's Individual Conversion Plan. While the conversion policy
may not be as comprehensive in coverage as your current group health policy, it will provide you
some degree of protection. In addition, the conversion policy may be higher than your current
group rates. Please check your current Evidence of Coverage and Disclosure Form (EOC/DF) for