Health Net

Local affordable health insurance that helps keep people healthy and companies growing. It is our mission to help people be healthy, secure and comfortable.

Provider Finder

Form Name Effective Date Download Form
New Group Submission
Small Group Business Submission Checklist
01/01/2018 Download
Employer Small Business Group Service Agreement
07/01/2018 Download
Electronic Check Form
01/01/2018 Download
Group Size Attestation Form
01/01/2018 Download
Participation Attestation Form - EnhancedCare Choice Promo 7.1 - 12.15.18 Effective Dates
07/01/2018 Download
Proof of Eligibility Statement for Sole Proprietor, Partner or Corporate Officer
01/01/2018 Download
Religious Organization Exemption Form
01/01/2018 Download
In Force Group Forms
Employer Group Size Verification Form
01/01/2018 Download
Open Enrollment Medical Plan Change Request Form 1.18-6.18
01/01/2018 Download
Open Enrollment Medical Plan Change Request Form 7.18
07/01/2018 Download
Open Enrollment Medical Plan Change Request Form 10.18
10/01/2018 Download
Renewal Date Change Request Form
01/01/2018 Download
Administration
Bank of America HSA Enrollment Packet
01/01/2018 Download
EFT Set Up Instructions
01/01/2018 Download
Employer Online Billing and Enrollment Brochure
01/01/2018 Download
Ensure Your Employees Understand Their Health Care
01/01/2018 Download
Group Administrator Registration Guide
01/01/2018 Download
Membership Accounting Information Sheet
01/01/2018 Download
SBC Employer Group Instructions Sheet
01/01/2018 Download
Understanding Your Billing Statement
01/01/2018 Download
Wellness Seminars Menu for Employers
01/01/2018 Download
Wellness Webinar Flyer for Employers
01/01/2018 Download
Form Name Effective Date Download Form
Enrollment and Change Forms
Small Group Employee Enrollment/Change Form 7.18 and Later Effective
07/01/2018 Download
Understanding the Continuity of Care Assistance Policy
01/01/2018 Download
Continuity of Care Assistance Form
01/01/2018 Download
Prescription Transition Form
01/01/2018 Download
Life Insurance Employee Enrollment/Change Form
01/01/2018 Download
Evidence of Insurability Form
01/01/2018 Download
Claim Forms
Authorization for Disclosure of PHI
01/01/2018 Download
Medical Claim Form
01/01/2018 Download
Prescription Drug Claim Form
01/01/2018 Download
Dental Claim Form
01/01/2018 Download
Vision Claim Form
01/01/2018 Download
Form Name Effective Date Download Form
2018 Medical HMO
Full HMO Network
Full Network HMO Platinum $10
01/01/2018 Summary SBC
Full Network HMO Platinum $10 w/Infertility
01/01/2018 SBC
Full Network HMO Platinum $20
01/01/2018 Summary SBC
Full Network HMO Platinum $20 w/Infertility
01/01/2018 SBC
Full Network HMO Platinum $30
07/01/2018 Summary SBC
Full Network HMO Platinum $30 w/Infertility
07/01/2018 SBC
Full Network HMO Gold $30
01/01/2018 Summary SBC
Full Network HMO Gold $30 w/Infertility
01/01/2018 SBC
Full Network HMO Gold $35
07/01/2018 Summary SBC
Full Network HMO Gold $35 w/Infertility
07/01/2018 SBC
Full Network HMO Gold $40
01/01/2018 Summary SBC
Full Network HMO Gold $40 w/Infertility
01/01/2018 SBC
Full Network HMO Silver $40
01/01/2018 Summary SBC
Full Network HMO Silver $40 w/Infertility
01/01/2018 SBC
WholeCare HMO Network
WholeCare HMO Platinum $10
01/01/2018 Summary SBC
WholeCare HMO Platinum $10 w/Infertility
01/01/2018 SBC
WholeCare HMO Platinum $20
01/01/2018 Summary SBC
WholeCare HMO Platinum $20 w/Infertility
01/01/2018 SBC
WholeCare HMO Platinum $30
07/01/2018 Summary SBC
WholeCare HMO Platinum $30 w/Infertility
07/01/2018 SBC
WholeCare HMO Gold $30
01/01/2018 Summary SBC
WholeCare HMO Gold $30 w/Infertility
01/01/2018 SBC
WholeCare HMO Gold $35
07/01/2018 Summary SBC
WholeCare HMO Gold $35 w/Infertility
07/01/2018 SBC
WholeCare HMO Gold $40
01/01/2018 Summary SBC
WholeCare HMO Gold $40 w/Infertility
01/01/2018 SBC
WholeCare HMO Silver $40
01/01/2018 Summary SBC
WholeCare HMO Silver $40 w/Infertility
01/01/2018 SBC
SmartCare HMO Network
SmartCare HMO Platinum $10
01/01/2018 Summary SBC
SmartCare HMO Platinum $10 w/Infertility
01/01/2018 SBC
SmartCare HMO Platinum $20
01/01/2018 Summary SBC
SmartCare HMO Platinum $20 w/Infertility
01/01/2018 SBC
SmartCare HMO Platinum $30
07/01/2018 Summary SBC
SmartCare HMO Platinum $30 w/Infertility
07/01/2018 SBC
SmartCare HMO Gold $30
01/01/2018 Summary SBC
SmartCare HMO Gold $30 w/Infertility
01/01/2018 SBC
SmartCare HMO Gold $35
07/01/2018 Summary SBC
SmartCare HMO Gold $35 w/Infertility
07/01/2018 SBC
SmartCare HMO Gold $40
01/01/2018 Summary SBC
SmartCare HMO Gold $40 w/Infertility
01/01/2018 SBC
SmartCare HMO Silver $40
01/01/2018 Summary SBC
SmartCare HMO Silver $40 w/Infertility
01/01/2018 SBC
CommunityCare HMO Network
CommunityCare HMO Gold $5
01/01/2018 Summary SBC
CommunityCare HMO Gold $5 w/Infertility
01/01/2018 SBC
CommunityCare HMO Silver $20
01/01/2018 Summary SBC
CommunityCare HMO Silver $20 w/Infertility
01/01/2018 SBC
CommunityCare HMO Bronze $45
01/01/2018 Summary SBC
CommunityCare HMO Bronze $45 w/Infertility
01/01/2018 SBC
Salud y Mas HMO Network
Salud HMO y Mas Platinum $10
01/01/2018 Summary SBC
Salud HMO y Mas Platinum $10 w/Infertility
01/01/2018 SBC
Salud HMO y Mas Platinum $20
01/01/2018 Summary SBC
Salud HMO y Mas Platinum $20 w/Infertility
01/01/2018 SBC
Salud HMO y Mas Platinum $30
07/01/2018 Summary SBC
Salud HMO y Mas Platinum $30 w/Infertility
07/01/2018 SBC
Salud HMO y Mas Gold $30
01/01/2018 Summary SBC
Salud HMO y Mas Gold $30 w/Infertility
01/01/2018 SBC
Salud HMO y Mas Gold $35
07/01/2018 Summary SBC
Salud HMO y Mas Gold $35 w/Infertility
07/01/2018 SBC
Salud HMO y Mas Gold $40
01/01/2018 Summary SBC
Salud HMO y Mas Gold $40 w/Infertility
01/01/2018 SBC
Salud HMO y Mas Silver $40
01/01/2018 Summary SBC
Salud HMO y Mas Silver $40 w/Infertility
01/01/2018 SBC
2018 Medical HSP
PureCare Platinum 90 HSP 0/15
01/01/2018 Summary SBC
PureCare Platinum 90 HSP 0/15 w/Infertility
01/01/2018 SBC
PureCare Gold 80 HSP 0/25
01/01/2018 Summary SBC
PureCare Gold 80 HSP 0/25 w/Infertility
01/01/2018 SBC
PureCare Silver 70 HSP 2000/45
01/01/2018 Summary SBC
PureCare Silver 70 HSP 2000/45 w/Infertility
01/01/2018 SBC
PureCare Bronze 60 HSP 6300/75
01/01/2018 Summary SBC
PureCare Bronze 60 HSP 6300/75 w/Infertility
01/01/2018 SBC
2018 Medical PPO
Full PPO Network
Platinum 90 PPO 0/15 + Child Dental
01/01/2018 Summary SBC
Platinum 90 PPO 0/15 + Child Dental w/Infertility
01/01/2018 SBC
Platinum 90 PPO 250/15 + Child Dental Alt (10.1.18 and Later Effective Dates)
10/01/2018 Summary SBC
Platinum 90 PPO 250/15 + Child Dental Alt w/Infertility (10.1.18 and Later Effective Dates)
10/01/2018 SBC
Gold 80 PPO 0/25 + Child Dental
01/01/2018 Summary SBC
Gold 80 PPO 0/25 + Child Dental w/Infertility
01/01/2018 SBC
Gold 80 PPO 1000/30 + Child Dental Alt (10.1.18 and Later Effective Dates)
10/01/2018 Summary SBC
Gold 80 PPO 1000/30 + Child Dental Alt w/Infertility (10.1.18 and Later Effective Dates)
10/01/2018 SBC
Gold 80 Value PPO 750/10 + Child Dental Alt
01/01/2018 Summary SBC
Gold 80 Value PPO 750/10 + Child Dental Alt w/Infertility
01/01/2018 SBC
Silver 70 PPO 2000/45 + Child Dental
01/01/2018 Summary SBC
Silver 70 PPO 2000/45 + Child Dental w/Infertility
01/01/2018 SBC
Silver 70 PPO 2000/55 + Child Dental Alt (10.1.18 and Later Effective Dates)
10/01/2018 Summary SBC
Silver 70 PPO 2000/55 + Child Dental Alt w/Infertility (10.1.18 and Later Effective Dates)
10/01/2018 SBC
Silver 70 Value PPO 1700/30 + Child Dental Alt
01/01/2018 Summary SBC
Silver 70 Value PPO 1700/30 + Child Dental Alt w/Infertility
01/01/2018 SBC
Silver 70 HDHP 1350/40 PPO + Child Dental Alt
01/01/2018 Summary SBC
Silver 70 HDHP 1350/40 PPO + Child Dental Alt w/Infertility
01/01/2018 SBC
Bronze 60 PPO 6300/75 + Child Dental
01/01/2018 Summary SBC
Bronze 60 PPO 6300/75 + Child Dental w/Infertility
01/01/2018 SBC
Bronze 60 HDHP 5600/15 PPO + Child Dental Alt
01/01/2018 Summary SBC
Bronze 60 HDHP 5600/15 PPO + Child Dental Alt w/Infertility
01/01/2018 SBC
EnhancedCare PPO Network
Platinum 90 EnhancedCare PPO 250/15 + Child Dental Alt (10.1.18 and Later Effective Dates)
10/01/2018 Summary SBC
Platinum 90 EnhancedCare PPO 250/15 + Child Dental Alt w/Infertility (10.1.18 and Later Effective Dates)
10/01/2018 SBC
Gold 80 EnhancedCare PPO 1000/30 + Child Dental Alt (10.1.18 and Later Effective Dates)
10/01/2018 Summary SBC
Gold 80 EnhancedCare PPO 1000/30 + Child Dental Alt w/Infertility (10.1.18 and Later Effective Dates)
10/01/2018 SBC
EnhancedCare PPO Gold Value
01/01/2018 Summary SBC
EnhancedCare PPO Gold Value w/Infertility
01/01/2018 SBC
Silver 70 EnhancedCare PPO 2000/55 + Child Dental Alt (10.1.18 and Later Effective Dates)
10/01/2018 Summary SBC
Silver 70 EnhancedCare PPO 2000/55 + Child Dental Alt w/Infertility (10.1.18 and Later Effective Dates)
10/01/2018 SBC
EnhancedCare PPO Silver Value
01/01/2018 Summary SBC
EnhancedCare PPO Silver Value w/Infertility
01/01/2018 SBC
Silver 70 HDHP 1350/40 EnhancedCare PPO + Child Dental Alt
01/01/2018 Summary SBC
Silver 70 HDHP 1350/40 EnhancedCare PPO + Child Dental Alt w/Infertility
01/01/2018 SBC
Bronze 60 HDHP 5600/15 EnhancedCare PPO + Child Dental Alt
01/01/2018 Summary SBC
Bronze 60 HDHP 5600/15 EnhancedCare PPO + Child Dental Alt w/Infertility
01/01/2018 SBC
2017 Medical HMO
Full HMO Network
Full Network HMO Platinum $10
01/01/2017 Summary SBC
Full Network HMO Platinum $10 w/Infertility
01/01/2017 SBC
Full Network HMO Platinum $20
01/01/2017 Summary SBC
Full Network HMO Platinum $20 w/Infertility
01/01/2017 SBC
Full Network HMO Gold $30
01/01/2017 Summary SBC
Full Network HMO Gold $30 w/Infertility
01/01/2017 SBC
Full Network HMO Gold $40
01/01/2017 Summary SBC
Full Network HMO Gold $40 w/Infertility
01/01/2017 SBC
Full Network HMO Gold $50
01/01/2017 Summary SBC
Full Network HMO Gold $50 w/Infertility
01/01/2017 SBC
WholeCare HMO Network
WholeCare HMO Platinum $10
01/01/2017 Summary SBC
WholeCare HMO Platinum $10 w/Infertility
01/01/2017 SBC
WholeCare HMO Platinum $20
01/01/2017 Summary SBC
WholeCare HMO Platinum $20 w/Infertility
01/01/2017 SBC
WholeCare HMO Gold $30
01/01/2017 Summary SBC
WholeCare HMO Gold $30 w/Infertility
01/01/2017 SBC
WholeCare HMO Gold $40
01/01/2017 Summary SBC
WholeCare HMO Gold $40 w/Infertility
01/01/2017 SBC
WholeCare HMO Gold $50
01/01/2017 Summary SBC
WholeCare HMO Gold $50 w/Infertility
01/01/2017 SBC
SmartCare HMO Network
SmartCare HMO Platinum $10
01/01/2017 Summary SBC
SmartCare HMO Platinum $10 w/Infertility
01/01/2017 SBC
SmartCare HMO Platinum $20
01/01/2017 Summary SBC
SmartCare HMO Platinum $20 w/Infertility
01/01/2017 SBC
SmartCare HMO Gold $30
01/01/2017 Summary SBC
SmartCare HMO Gold $30 w/Infertility
01/01/2017 SBC
SmartCare HMO Gold $40
01/01/2017 Summary SBC
SmartCare HMO Gold $40 w/Infertility
01/01/2017 SBC
SmartCare HMO Gold $50
01/01/2017 Summary SBC
SmartCare HMO Gold $50 w/Infertility
01/01/2017 SBC
CommunityCare HMO Network
CommunityCare HMO Gold $5
01/01/2017 Summary SBC
CommunityCare HMO Gold $5 w/Infertility
01/01/2017 SBC
CommunityCare HMO Silver $20
01/01/2017 Summary SBC
CommunityCare HMO Silver $20 w/Infertility
01/01/2017 SBC
Salud y Mas HMO Network
Salud HMO y Mas Platinum $10
01/01/2017 Summary SBC
Salud HMO y Mas Platinum $10 w/Infertility
01/01/2017 SBC
Salud HMO y Mas Platinum $20
01/01/2017 Summary SBC
Salud HMO y Mas Platinum $20 w/Infertility
01/01/2017 SBC
Salud HMO y Mas Gold $30
01/01/2017 Summary SBC
Salud HMO y Mas Gold $30 w/Infertility
01/01/2017 SBC
Salud HMO y Mas Gold $40
01/01/2017 Summary SBC
Salud HMO y Mas Gold $40 w/Infertility
01/01/2017 SBC
Salud HMO y Mas Gold $50
01/01/2017 Summary SBC
Salud HMO y Mas Gold $50 w/Infertility
01/01/2017 SBC
2017 Medical HSP
PureCare Platinum 90 HSP 0/15
01/01/2017 Summary SBC
PureCare Platinum 90 HSP 0/15 w/Infertility
01/01/2017 SBC
PureCare Gold 80 HSP 0/30
01/01/2017 Summary SBC
PureCare Gold 80 HSP 0/30 w/Infertility
01/01/2017 SBC
PureCare Silver 70 HSP 2000/45
01/01/2017 Summary SBC
PureCare Silver 70 HSP 2000/45 w/Infertility
01/01/2017 SBC
PureCare Bronze 60 HSP 6300/75
01/01/2017 Summary SBC
PureCare Bronze 60 HSP 6300/75 w/Infertility
01/01/2017 SBC
2017 Medical EPO
PureCare Gold 80 EPO 1300/20 Alternate
01/01/2017 Summary SBC
PureCare Gold 80 EPO 1300/20 Alternate w/Infertility
01/01/2017 SBC
PureCare Silver 70 EPO 2000/20 Alternate
01/01/2017 Summary SBC
PureCare Silver 70 EPO 2000/20 Alternate w/Infertility
01/01/2017 SBC
2017 Medical PPO
Full PPO Network
Platinum 90 PPO 0/15
01/01/2017 Summary SBC
Platinum 90 PPO 0/15 w/Infertility
01/01/2017 SBC
Gold 80 PPO 0/30
01/01/2017 Summary SBC
Gold 80 PPO 0/30 w/Infertility
01/01/2017 SBC
PPO Gold 80 Value
01/01/2017 Summary SBC
PPO Gold 80 Value w/Infertility
01/01/2017 SBC
Silver 70 PPO 2000/45
01/01/2017 Summary SBC
Silver 70 PPO 2000/45 w/Infertility
01/01/2017 SBC
PPO Silver 70 Value
01/01/2017 Summary SBC
PPO Silver 70 Value w/Infertility
01/01/2017 SBC
PPO Silver HSA
12/01/2017 Summary SBC
PPO Silver HSA w/Infertility
12/01/2017 SBC
Bronze 60 PPO 6300/75
01/01/2017 Summary SBC
Bronze 60 PPO 6300/75 w/Infertility
01/01/2017 SBC
PPO Bronze HSA
01/01/2017 Summary SBC
PPO Bronze HSA w/Infertility
01/01/2017 SBC
EnhancedCare PPO Network
EnhancedCare PPO Gold Value
12/01/2017 Summary SBC
EnhancedCare PPO Gold Value w/Infertility
12/01/2017 SBC
EnhancedCare PPO Silver Value
12/01/2017 Summary SBC
EnhancedCare PPO Silver Value w/Infertility
12/01/2017 SBC
EnhancedCare PPO Silver HSA
12/01/2017 Summary SBC
EnhancedCare PPO Silver HSA w/Infertility
12/01/2017 SBC
EnhancedCare PPO Bronze HSA
12/01/2017 Summary SBC
EnhancedCare PPO Bronze HSA w/Infertility
12/01/2017 SBC
2018 Dental Plans
DHMO Plans
DHMO Plus 150
01/01/2018 Summary
DHMO Plus 225
01/01/2018 Summary
Dental PPO Plans
DPPO Classic 4 1500
01/01/2018 Summary
DPPO Classic 5 1500
01/01/2018 Summary
DPPO Essential 2 1000
01/01/2018 Summary
DPPO Essential 5 1500
01/01/2018 Summary
DPPO Essential 6 1500
01/01/2018 Summary
2018 Vision Plans
Preferred Value Plan 10-2
01/01/2018 Summary
Preferred Value Plan 1025-2
01/01/2018 Summary
Preferred Value Plan 1025-3
01/01/2018 Summary
2018 Basic Group Term Life/AD&D
Basic Term Life with AD&D Summary - this form is customizable to allow for the addition of benefit level ($15,000, $25,000 or $50,000)
01/01/2018 Summary
Form Name Effective Date Download Form
General Information
Health Net Small Group 2018 Q3-Q4 Broker Bonus
07/01/2018 Download
Health Net 2018 Q3-Q4 Underwriting Promotions
07/01/2018 Download
Health Net Small Group Broker Porfolio Guide January 2018
01/01/2018 Download
Health Net Small Group Broker Porfolio Guide July 2018
07/01/2018 Download
Health Net Small Group Portfolio Desktopper January 2018
01/01/2018 Download
Health Net Small Group Portfolio Desktopper July 2018
07/01/2018 Download
Health Net Small Group Portfolio Desktopper October 2018
10/01/2018 Download
2018 Small Group Renewal Guide
01/01/2018 Download
Provider Search Instructions
01/01/2018 Download
Mobile App Flyer
01/01/2018 Download
Top Reasons to Sell Health Net
01/01/2018 Download
Top Reasons for Selling Health Net's Salud Plans
01/01/2018 Download
Top 10 Reasons for Employee Enrollment Delays
01/01/2018 Download
Medical
California MinuteClinic Listing
01/01/2018 Download
Decision Power Healthy Discounts Flyer
01/01/2018 Download
Decision Power Member Brochure
01/01/2018 Download
Employee Assistance Programs & Behavioral Health Services Brochure
01/01/2018 Download
Employee Guide to Health Net Benefits
01/01/2018 Download
ER vs Urgent Care Flyer
01/01/2018 Download
Generic vs Brand-Name Drugs Information
01/01/2018 Download
Getting Started with Mail Order Pharmacy Kit
01/01/2018 Download
Heal Flyer for PPO Members
05/01/2018 Download
Health Coaching Program
01/01/2018 Download
Health Net Network Comparison List - Central California
02/01/2018 Download
Health Net Network Comparison List - Los Angeles County
02/01/2018 Download
Health Net Network Comparison List - Northern California
02/01/2018 Download
Health Net Network Comparison List - Orange County
02/01/2018 Download
Health Net Network Comparison List - Riverside County
02/01/2018 Download
Health Net Network Comparison List - San Bernardino County
02/01/2018 Download
Health Net Network Comparison List - San Diego County
02/01/2018 Download
Health Net Beginnings Open Enrollment Flyer
01/01/2018 Download
Health Net Preventive Screening Guidelines
01/01/2018 Download
HSA Employee Brochure
01/01/2018 Download
HSA Employer Brochure
01/01/2018 Download
Infertility Rider Benefits
01/01/2018 Download
myStrength Program Flyer
01/01/2018 Download
Out-of-State Employee PPO Flyer
01/01/2018 Download
PPO Fast Facts
01/01/2018 Download
PPO Open Enrollment Brochure
01/01/2018 Download
Prior Carrier Deductible Credit Flyer
01/01/2018 Download
PureCare HSP Flyer
01/01/2018 Download
Salud Con Health Net Broker-Employer Overview
01/01/2018 Download
Salud HMO y Mas Member Brochure-Bilingual
01/01/2018 Download
Salud HMO y Mas Service Area
01/01/2018 Download
Text4Baby Flyer
01/01/2018 Download
Travel Guide - HMO and POS plans
01/01/2018 Download
Travel Guide - PPO plans
01/01/2018 Download
Uniform Glossary of Health Coverage and Medical Terms
01/01/2018 Download
Vision Flyer for Medical HMO Members
01/01/2018 Download
Dental
Dental Overview Flyer
01/01/2018 Download
Dental Member Website Flyer
01/01/2018 Download
Dental Provider Search Instructions
01/01/2018 Download
Vision
Vision Plan FAQ
01/01/2018 Download
Vision Member Website Flyer
01/01/2018 Download
Life
Health Net Life Product Guide
01/01/2018 Download
Form Name Effective Date Download Form