Online Enrollment
Confirmation Number:
Plan Name:
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Name & Address
First: None Entered
Middle initial (optional): None Entered
Last: None Entered
Street Address (P.O. Box is not allowed): None Entered
Street Address 2 (optional): None Entered
City: None Entered
Zip Code: None Entered
State: None Entered
County: None Entered
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Is your mailing address the same as your residence address? None Entered
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Phone
Phone number: None Entered
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I would like to receive text messages from SCAN (optional) None Entered
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I would like to have my materials sent online. Not Applicable
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Medicare
Medicare number: None Entered
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Special Enrollment Period Not Applicable
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Primary Care Doctor
PCP Name: None Entered
PCP Number: None Entered
Medical Group Name: None Entered
Medical Group Address Suffix: None Entered
Medical Group Number: None Entered
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Dental Information (optional)
Dental provider ID number (optional): None Entered
Dental office name (optional): None Entered
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Will you have other prescription drug coverage (like VA, TRICARE) in addition to SCAN? None Entered
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Do you have Continuity of Care needs? None Entered
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Personal Identification
Date of Birth: None Entered
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Race-ethnicity Not Applicable
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Ethnicity Not Applicable
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What is your sex? Not Applicable
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What is your preferred spoken language?
Select your spoken language: None Entered
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What is your preferred written language?
Select your written language: None Entered
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Are you enrolled in your state Medi-Cal (Medicaid) program? None Entered
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Do you have an Emergency Contact? (Optional)
Enter your emergency contact (optional): None Entered
Relationship to you: None Entered
Phone Number: None Entered
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Do you work? (Optional) None Entered
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Does your spouse work? (Optional) None Entered
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Select one below if you want us to send you information in an accessible format (Optional) None Entered
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Zero Payment