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
CCA Medicare Dual Special Needs Plan RI – Prescription Reimbursement Form
Vision Reimbursement Form
Other Important Forms
Chronic Condition Form
Appointment of Representative Form
CCA Rhode Island – Prescription Drug Coverage Determination Request Form
CCA Senior Care Options – Request for Redetermination of Medicare Prescription Drug Denial
Costco Mail Order Pharmacy Form
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.