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Identification Card Request

Online Form

Contra Costa Health Plan
595 Center Avenue, Suite 100
Martinez, CA 94553

To request a new I.D. Card, please use the Online Form below then Submit.

Form must be fully completed before request can be processed.
Card should be received within 2 weeks of request.

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Male     Female


Relationship to member:

To request additional I.D. Cards for family members please complete and submit additional forms for each family member.

If this form was not completed by member or member's legal guardian, we will be unable to process request without member's explicit agreement.