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Reimbursement Forms

CCA Medicare Advantage Plans (RI) – Prescription Reimbursement Form

Other Important Forms

Chronic Condition Form

CCA Rhode Island – Prescription Drug Coverage Determination Request Form

Financial Hardship Policy

Financial Assistance Application

Vaccine Coverage Determination 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.

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