Member forms
Administrative Forms
Authorization for Disclosure of Protected Health Information
CCA Health California – Member Reimbursement Form
Drug Coverage Decision Request Form
Over-the-Counter (OTC) Catalog
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Appeals and Grievances
Chronic Condition Form
Appointment of Representative Form
Appeal Form for Drugs
Grievance (Complaint) and Appeal Form
Medical Coverage Decision Request Form
Have a Friend Interested in CCA? Let Us Know
Submit This Form on Your Friend’s Behalf
Our team can help you:
- Schedule an in-person appointment
- Understand our plans and benefits
- Check if your doctor is in our network
- Find out your prescription costs
- Enroll in a plan
To refer a friend, please fill out this form.
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Thank You for the Referral
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