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Hospital Block Transfer Filing Form


Download Hospital Block Transfer Filing Form - MS Word

If a plan assigns enrollees to a hospital and has an upcoming contract termination with a hospital, at least 75-days prior to the contract termination, a Block Transfer filing must be made with the Department.

If fewer than 2,000 enrollees are assigned to the hospital, a Block Transfer filing does not need to be made with the Department. An Enrollee Transfer Notice, that complies with Rule 1300.67.1.3(b)(1) would, however, need to be sent to Affected Enrollees who are assigned to the Terminated Hospital at least 60-days prior to the contract termination. The notice must be approved by the Department.

Plans must complete the Hospital Block Transfer Filing Form and then email the form to the following address: termination@dmhc.ca.gov. The form must be completed in its entirety, with all necessary attachments provided.



 
 
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