Instructions on How to Fill out Your Enrollment Form

Note: If you need this or any information in another language please call Contra Costa Health Plan. The phone number and hours of operation are listed below. You can only enroll in SelectCare if you are dually eligible for Medi-Cal and Medicare. "Dually eligible" means that you are entitled to both the Medi-Cal and Medicare programs. You must be fully Medi-Cal eligible with no share of coast and entitled to Part A and also enrolled in Medicare Part B to be a member of SelectCare. You must reside in Contra Costa County and use our provider networks for all of your routine care.

Download and print the Enrollment Form (166k PDF, 4pp).

Please have the following information available so you can transfer it to the enrollment form:
1. Your Medicare Card or a copy of your Medicare claim number
2. The name and phone number of your Emergency Contact
3. Your Social Security Card or number
4. The name and ID number of any prescription insurance plan that you currently belong to
5. If you live in any type of assisted living facility, the name, address and phone number of the facility
6. Your Medi-Cal card or beneficiary number - Please make a copy of your Medi-Cal (Benefits Identification Card) and enclose it with your application.
Use a pen and fill out all of the boxes.
Print clearly.
Don't forget to sign the last page.
If you are unable to sign, have your authorized representative sign the form where indicated.
You may enclose a check for $16.27 with your application and we will bill you monthly. You may choose instead to have your premium automatically deducted from your Social Security check. Remember, that you generally must stay with the payment option you choose for the rest of the year.
If you need additional information or want to discuss any of the documents in this package please call Contra Costa Health Plan's SelectCare offices.

After you have completed the form, please mail it with the required documentation in the enclosed pre-addressed envelope to:

SelectCare
Contra Costa Health Plan
595 Center Avenue, Suite 100
Martinez, CA 94553

If you have any questions, or need help in filling out your form, please call Contra Costa Health Plan at 1-877-661-6230, daily from 8 a.m.- 8 p.m. For the California Relay/TTY for the hearing impaired, please call 1-800-735-2929. (After March 1st, you may leave a message Saturday and Sunday, and your call will be returned the next business day).