Skip to main content

Reimbursement Forms

CCA Member Reimbursement Form

CCA Senior Care Options – Prescription Reimbursement Form

Vision Reimbursement Form

Other Important Forms

Appointment of Representative Form

CCA Massachusetts – Prescription Drug Coverage Determination Request Form

CCA Senior Care Options – Request for Redetermination of Medicare Prescription Drug Denial


Costco Mail Order Pharmacy Form

Vaccine Coverage Determination Request Form

Part D Late Enrollment Penalty (LEP) Reconsideration 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.

We’re here to support you

866-610-2273 (TTY 711)
April to September, 8 am – 8 pm, Monday – Friday