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 Senior Care Options – Prescription Reimbursement Form
CCA Senior Care Options – Prescription Drug Coverage Determination Request Form
Vision Reimbursement Form
Other Important Forms
Appointment of Representative Form
CCA Senior Care Options (HMO D-SNP) – Request for Reconsideration of Medicare Prescription Drug Denial
CCA Senior Care Options – Request for Redetermination of Medicare Prescription Drug Denial
CVS Caremark Mail Order Pharmacy 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.