QExA HAWAI`I CHOICE Form

QExA HAWAI`I PO Box 135038 Honolulu, HI 96801

If you want to send in your health plan choice, please fill out this form and mail it to us at the address shown above. You can also fax it toll-free to 1-866-535-7620. Or, if you want, you can choose a health plan over the phone, call the toll-free Helpline at 1-866-928-1959.

PLEASE PRINT

Client Last Name

First Name

Middle Initial

Date of Birth

Address

Apt. No.

City

State

Zip Code

Medicaid ID Number

Home Phone Number

My 1st choice for my QExA health plan is (circle your 1st choice): Evercare `Ohana Health Plan

My 2nd choice for my QExA health plan is (circle your 2nd choice): Evercare `Ohana Health Plan

Name of Doctor (Primary Care Provider)

Client Signature

Date signed

Questions … call toll-free 1-866-928-1959 (TTY toll-free 1-866-928-1958) to talk with an Enrollment Counselor.

If form is completed by Legal Representative:

I (write in First & Last Name) am the Legal Representative and made the above health plan choice for (write in First & Last Name of client)

Sign here (Legal Representative)

Date signed

Daytime Telephone Number