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Reimbursement Forms

CCA Medicare Dual Special Needs Plan RI – Prescription Reimbursement Form

Other Important Forms

Chronic Condition Form

CCA Rhode Island – Prescription Drug Coverage Determination Request Form

CCA Senior Care Options – Request for Redetermination of Medicare Prescription Drug Denial

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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