California Department of Managed Health Care > Health Care in California > Your Health Care Rights > Disability Access

Disability Coordinator Contact Form

The Department of Managed Health Care (DMHC) is committed to providing you with accessible communication. Please use the form below to contact the DMHC Disability Coordinator with questions, request materials from the DMHC in an alternate format, or provide the DMHC with feedback.

Request Alternate Format Form

If you see this, leave this form field blank

Comments: *

If you would like to receive a response to your comments, please complete the following:
Yes, I would like to receive a response.

Your Name:

E-mail Address:

Daytime Phone:

Mailing Address:

City:

State:

Zip Code:

Preferred Communication Mode:

California Relay Service

Braille

Large Print

Other

If other, please specify format:

Alternate Format Request Form

To request an alternate format document, please provide the following information. If you would like to request multiple alternate formats, please use the "Additional Details" field to provide details of your request.

Document Title:

Link to document or webpage:

Alternative Format:

Braille

Large Text

Other Format

If other, please specify format:

Communication Assistance:

ASL Interpreter Services

Other Communication Assistance

If other, please specify format:

Additional Details:

Please provide your contact information below:

Your Name:

E-mail Address:

Daytime Phone:

Mailing Address:

City:

State:

Zip Code: