Member Forms
On this page you’ll find important forms you can use to request coverage exceptions, reimbursements, and more
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 Reconsideration of Medicare Prescription Drug Denial
One Care Request for Redetermination of Medicare Prescription Drug Denial
CCA One Care – Prescription Drug Coverage Determination Request Form
Costco Mail Order Pharmacy Form (2024)
CVS Caremark Mail Order Pharmacy Form (2025)
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.