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Reimbursement Forms

CCA Member Reimbursement Form

CCA One Care – Prescription Reimbursement Form

Vision Reimbursement Form

Other Important Forms

Appointment of Representative Form

One Care Request for Redetermination of Medicare Prescription Drug Denial


CCA Massachusetts – Prescription Drug Coverage Determination Request Form

Costco Mail Order Pharmacy Form

Vaccine Coverage Determination Request Form

Release of Information (ROI) Form

This form is used to release your health information from CCA to a person or organization. It can also be used to request your health information from a person or organization, such as a healthcare provider or hospital, to be shared with CCA.

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