Transportation Online Referral Form

Birthdate*

Phone*

Email*

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SOCIAL HISTORY

THE GAY BISEXUAL AND TRANSGENDER DISPARITIES REDUCTION ACT OF 2016 (AB 959)

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MILITARY SERVICE

Contact the California Department of Veterans Affairs (CalVet) to determine eligibility for services and supports at www.calvet.ca.gov or (800) 952-5626. You can also contact the Ventura County Veteran Services office at (805) 477-5155 for more information.

PLEASE LOOK AT YOUR PRESCRIPTION DRUG CARD / HEALTH PLAN CARD AND LOOK FOR PDP OR HMO

If yes, enter effective date:

Please specify name of plan

Specify preferred pharmacy*

YOU MAY BE ELIGIBLE TO SAVE ON PRESCRIPTION DRUG COSTS & QUALIFY FOR OTHER PROGRAMS

What is your share-of-cost (SOC) amount?*

PRESCRIPTION DRUGS

The information you provide will inform our comparison. TIP: Pull out your medication bottles and transcribe the full name of the drug(s) into the field(s) below.

ADDITIONAL INFORMATION

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Please indicate the reason why you are requesting an appointment with a HICAP counselor.*

DISCLOSURE STATEMENT

HICAP counseling services are provided by trained counselors, registered by the California Department of Aging, who are acting in good faith to provide independent, impartial information about health insurance policies and benefits to clients. Counselors do not sell any type of health care coverage. They do not endorse or recommend any specific plan or policy. Information presented by HICAP volunteers should not be construed to be legal advice, and volunteers are not liable for acts and omissions in providing counseling to recipients of service. Welfare and Institutions Code, Section 9541 (1)(4)

By entering your name and date below, you acknowledge that you have read and understand this disclosure.*

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Area Agency on Aging

VCAAA

Advisory Council

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