Common Forms

Appeals and Grievance Form  Use this form to request a decision appeal, or to file a formal complaint.

Appointment of Representative Form  Use this form to appoint a person to act for you about your appeal or rights

Authorization for Release of Protected Health Information (PHI)  Use this form to authorize CalOptima to release your protected health information (PHI) to another person or organization. See next item below, on how to complete this form.

Compliance and Fraud, Waste and Abuse Reporting Form  Use this form to report a suspected non-compliance issue or fraud, waste and abuse (FWA). The confidential form has instructions on how to fill it out and where to send it. You do not have to give your name to report suspected fraud or abuse.

Instruction Sheet for CalOptima Health Insurance Portability and Accountability Act (HIPAA); Authorization for Release of Protected Health Information (PHI)  Read this to see how to complete the above form.

Individual Request for Protected Health Information (PHI) Access  CalOptima members, past and current, can use this form to request copies of their protected health information (PHI).

Member Request to Amend Protected Health Information (PHI)  If you believe part of your Protected Health Information (PHI) is not correct, use this form to request a change.

Prescription Drugs Payment Request Form  Use this form to pay you back for our share of the cost of a drug.

Request for an Accounting of Disclosure  Use this form to request a record of how your Protected Health Information (PHI) was disclosed by CalOptima.

Request for Restriction on Manner/Method of Confidential Communications  Use this form if you would like to request to receive confidential communications of Protected Health Information (PHI) by different ways or to a different address.

Request for Restriction on Use and Disclosure of Protected Health Information (PHI)  Use this form if you would like to request that CalOptima limit the disclosure of parts of your Protected Health Information to certain persons or organizations.

Revocation of Authorization for Release of Protected Health Information  Use this form if you would like to revoke, withdraw, and stop an authorization you gave to CalOptima to disclose your Protected Health Information (PHI) to a previously authorized recipient.

Statement Of Disagreement  If you requested to change your Protected Health Information (PHI) and CalOptima denied your request, you may use this form to request that CalOptima include the request and denial in future disclosures of your PHI.

Termination of Restriction Form  If you previously submitted a request to restrict the disclosure of your Protected Health Information (PHI), use this form to end that restriction.