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Reimbursement Forms

CCA Medicare Advantage Plans (RI) – Prescription Reimbursement Form

Other Important Forms

CCA Rhode Island – Prescription Drug Coverage Determination Request Form

Financial Hardship Policy

Financial Assistance Application

Member Chronic Condition Coverage Request Form (RI)

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.

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.

Vaccine Coverage Determination Request Form

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