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
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CCA Medicare Advantage Plans (RI) – Prescription Reimbursement Form
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Vision Reimbursement Form
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Other Important Forms
Appointment of Representative Form
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CCA Rhode Island – Prescription Drug Coverage Determination Request Form
Costco Mail Order Pharmacy Form
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Financial Hardship Policy
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Financial Assistance Application
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Vaccine Coverage Determination Request Form
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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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