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.