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Form for

"Request For Plan Information"

letter to Managed Care Organization

Subscriber Information

Full Name
Street Address
City, State, Zip
ID Number

Group or Plan Information

Plan Name
Addressee
Street Address
City, State, Zip
ID Number

Type of Plan

Private Employer Medicare MediCal Other California

Optional Items

Dates of prior fruitless phone calls
Persons to get Copies, eg: employer, regulatory agencies.

Attachment(s): {copy and attach any provisions from your Evidence of Coverage or member handbook that states you are entitled to the information you are requesting}