Member forms
On this page you’ll find important forms you can use to request coverage exceptions, request prior authorization, and more.
Administrative Forms
Prior Authorization Form MI
Authorization to Release PHI MI
Appeals and Grievances
Coverage Determination Form (OptumRx) MI
Redetermination Request Form MI
Coverage Determination Forms MI
File a Complaint MI
Appointment of Representative Form
Appointment of Representative Form
Other Important Forms
Chronic Condition Form
Have a Friend Interested in CCA? Let Us Know
Submit This Form on Your Friend’s Behalf
Our team can help you:
- Schedule an in-person appointment
- Understand our plans and benefits
- Check if your doctor is in our network
- Find out your prescription costs
- Enroll in a plan
To refer a friend, please fill out this form.
All fields are required.
Thank You for the Referral
the number you provided