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
Appointment of Representative Form
Appeal Form for Drugs
Grievance (Complaint) and Appeal Form
Medical Coverage Decision Request Form
Member Chronic Condition Coverage Request Form (CA)
Our members with certain health conditions or adverse health outcomes may be eligible for additional benefits under the Special Supplemental Benefits for the Chronically Ill (SSBCI). This form should be used by members to request that CCA determine eligibility for SSBCI benefits.
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.
All fields are required.
Thank You for the Referral
the number you provided