Identification Card Request

Your ID card will come printed on paper. You will need to tear off the card out from the sheet of paper.

You can also access your card online anytime on MyChart.
Pull up your ID card on your phone or download and print it.
Sign up for MyChart today at mychart.cchealth.org! You can sign up for MyChart without an activation code.

Online Form

Contra Costa Health Plan
595 Center Avenue, Suite 100
Martinez, CA 94553
877-661-6230

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.

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.

LAST Name:
FIRST Name:
Middle Initial:
Birthdate: (mm/dd/yyyy)	/ /
Sex:	Male Female
Telephone Number: (999-999-9999)	Home: Cellphone:
E-mail:
Home Street Address:
City:
State:
Zip:
Member I.D. # (optional) (found on CCHP ID Card):
Last 4 digits of Social Security Number:
Name of person submitting request:	Relationship to member:


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