Forms and referrals
We want to make it easy to work together so our members, and your patients, have the best experience possible. Here you can access important provider forms and learn how to refer a patient to CCA Health.
Jump to: Administrative Forms & Notices | Prior Authorization Forms | Claims Requirements | CMS Provider Directory Requirements
Refer a Patient
Together we can create a better experience and better outcomes for your patients with complex needs.
Administrative Forms and Notices
Appointment of Representative (Form CMS-1696)*
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2023 PA Select Drug Exception List – Rhode Island
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2023 Prior Authorization Requirements – Rhode Island
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Coverage Requests and Determination – Rhode Island
Learn how we make coverage decisions and how to make requests for coverage.
2023 Durable Medical Equipment – Rhode Island
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2023 Ambulatory – Outpatient Surgery Exception List – Rhode Island
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Notice of Privacy Practices – Rhode Island
Commonwealth Care Alliance, Inc., is required by law (i) to protect the privacy of your Medical Information
Physician Peer-to-Peer Request Form
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The Patient Health Questionnaire 2 Overview (PHQ 2)
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The Patient Health Questionnaire (PHQ 9)
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Mental Status Exam
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CAGE Questionnaire
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FAQs: Prior Authorization Requests – Rhode Island
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Esketamine Prior Authorization Request
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PA Form – Repetitive Transcranial Magnetic Stimulation Request (RI)
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PA Form – Out of Network Psychological & Neuropsychological Assessment (RI)
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PA Form – Cardiac Imaging
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PA Form – CT/CTA/MRI
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PA Form – PET – PET CT
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Standard Prior Authorization Request Form
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CCA ECT Authorization Request
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CMS Provider Directory Requirements
Guidance to Verify Adequate Networks & Current Provider Directories
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Provider Directory Requirements
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