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Get CA Santa Clara Family Health Plan 50189E 2017-2024

T for you in most health care matters, and may use, receive, disclose your Protected Health Information. If you have any questions, please call Member Services at 1-800-260-2055. TTY/TDD users call 1-800-735-2929. Please return the completed form to Attn: Customer Service, Santa Clara Family Health Plan, 210 E. Hacienda Ave, Campbell, CA 95008, or fax it to 1-408-874-1965. Section 1 Appointment of Representative To be completed by the Member or Minor s parent/guardian. Name of Member: Memb.

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