Forms for Members

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.

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.

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:

• Coronary Artery Disease
• Diabetes
• Asthma

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.

Diabetic Retinal Eye Exams (DRE) Incentive Form
Maintaining a healthy lifestyle includes having regular preventive screenings such as dilated retinal eye (DRE) exams. Annual DRE exams are especially important for early detection of retinopathy due to diabetes that can cause loss of eyesight.

When you complete your DRE exam, WHA will send you one of the following gift cards worth $25 with proof of your exam.

• Home Depot®
• Target®
• 2 Movie Tickets

*Limited to one per year.
Members qualify for the incentive programs when they obtain the services from a WHA provider/facility within a year and were active with WHA at the time of the service. For more information about these programs or other services, contact Member Services at 916-563-2250 and ask to speak with a Health Promotion and Disease Management (HPDM) representative.

Breast Cancer Screening (BCS) Incentive Form
Women between the ages of 40-69 years of age can qualify to have their names entered for a drawing to win one of the following $100 gift cards:

• Home Depot®
• Target®
• Visa Gift Card

*Limited to one per year.
Members qualify for the incentive programs when they obtain the services from a WHA provider/facility within a year and were active with WHA at the time of the service. For more information about these programs or other services, contact Member Services at 916-563-2250 and ask to speak with a Health Promotion and Disease Management (HPDM) representative.

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.

WHA supplies this rate information pursuant to California Health and Safety Code section 1385.07(d).

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.

• Membership Agreement and Disclosure Form and Evidence of Coverage
• Enrollment Form
• Electronic Funds Transfer Agreement

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 eligibility requirements.

It is your responsibility to apply for this coverage with WHA. If you fail to contact WHA then your option to enroll in the conversion policy will be lost.

Once forms and premiums are received, WHA will review the information that all eligibility requirements are met. If you are not eligible for the conversion plan, WHA will advise you of the reason in writing and premiums will be refunded. Otherwise, your coverage will become effective on the first day following your termination date under your previous employer group health plan, allowing for no lapse of coverage. Should you have any questions, you may contact our COBRA/Conversion Specialist at (916)563-2214.