| Front |
Back |
| Name of Health Plan |
Member Services Contact Information |
| Program Name - STAR or CHIP |
What to do in an Emergency |
| Member Name |
Referral Service Information |
| Member Identification Number/Date of Birth |
Behavioral Health Contact information |
| Name of Primary Care Physician |
Vision Benefit Contact Information |
| Phone Number for Primary Care Physician |
Provider Service Contact Information |
| Effective Date of Primary Care Physician |
Claims Submission Information |
| Date the ID Card Was Issued |
|
