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
Prior Authorization Request Form (OptumRx) MI
Redetermination Request Form MI
File a Complaint MI
When you click the link below, you will leave the CCA Health Michigan, Inc. website and land on Medicare.gov.
Appointment of Representative Form
Appointment of Representative Form
Other Important Forms
Member Chronic Condition Coverage Request Form (MI)
Our members with certain health conditions or adverse health outcomes may be eligible for additional benefits under the Special Supplemental Benefits for the Chronically Ill (SSBCI). This form should be used by members to request that CCA determine eligibility for SSBCI benefits.
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April 1 to September 30, 8 am – 8 pm, Monday – Friday