Common Forms

Appeal for Reconsideration of Denial  Use this PACE form, to appeal a denial

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  Use this form to authorize CalOptima Health 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 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.

Grievance Form  Use this PACE form to file a grievance.

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

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 Health to disclose your Protected Health Information (PHI) to a previously authorized recipient.

PACE Referral Form  Use this form to refer someone to PACE.