Skip to main content

Administrative Forms

Authorization for Disclosure of Protected Health Information

CCA Health California – Member Reimbursement Form

Over-the-Counter (OTC) Catalog

Appeals and Grievances

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.

We’re here to support you

866-333-3530 (TTY 711)
April 1 to September 30, 8 am – 8 pm (PT), Monday – Friday