HPSM CareAdvantage Members Registration Form

Fitness Membership Program Application for CareAdvantage Members

Complete all fields for qualifying members in household.
Completing Form for*
YMCA Service Location*
Participant Name*

TitleFirst NameMiddle NameLast NameSuffix
Gender*
Ethnicity*
Birth Date*

MonthDayYear
HPSM CareAdvantage Member ID. Please refer to your HPSM CareAdvantage member ID card and enter the number exactly as written. *
E-mail
No email address? Please type noemail@noemail.com
Home Phone
No home phone? Please type (000) 000-0000
Cell Phone
No cell phone? Please type (000) 000-0000
Prefered Contact line
Prefered Contact Method
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Emergency Contact*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship to Participant*
CareAdvantage Dual Special Needs Plan (D-SNP) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Enrollment in CareAdvantage depends on contract renewal. YMCA of San Francisco is not part of the HPSM. Participation in this program is optional and does not affect your Medi-Cal or Medicare coverage.
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Fitness Membership Program Application for CareAdvantage Members