• To Report Fraud, Waste and Abuse
  • Call ECHP's Hotline: 866 678-8355

24 Hr Nurse Advice Hotline (800) 581-9952

Find a Doctor
Find a Doctor
Find a Hospital
Find a Hospital
Find a Pharmacy
Find a Pharmacy
Appointment of Representative Form

Easy Choice Health Plan

This form confirms your request for a particular person to act as your representative in connection with a claim.

Download the Appointment of Representative Form by clicking on your preferred language below.

No ImageEnglish Appointment of Representative Form [PDF, 72KB]

No ImageSpanish Appointment of Representative Form [PDF, 32KB]

Please complete your form and mail to:
Easy Choice Health Plan
PO BOX 6025
Cypress, CA 90630

You may also fax your form to:
(877) 999-3945

Customer Service Phone:
(866) 999-3945

If you have any questions when completing this form, call the Customer Service number listed on the back of your member ID card.

 

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