Common Forms

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Questions

Preguntas
Câu Hỏi
سئوالات
질문
الأسئلة
問題

If you have questions or need help with your health care, please call our Customer Service Department at:

1-714-246-8500
1-888-587-8088 (toll free)

24 hours a day, 7 days a week.

Members with hearing or speech impairments can call the TDD/TTY line at 1-800-735-2929.

We also provide interpreter services at no cost to our members.

We have staff who speak your language.

Tenemos personal que habla su idioma.

Chúng tôi có nhân viên nói cùng ngôn ngữ với quý vị

ما پرسنلی را در استخدام داریم که به زبان شما تکلم می کنند.

여러분의 언어를 하는 직원이 있습니다.

ما پرسنلی را در استخدام داریم که به زبان شما تکلم می کنند

我們有工作人員會講您的語言。

Find Common Forms

We want to make it easy for you to find the forms you need. If you don't see the form you are looking for, or if you are not sure which one you need, please call CalOptima's Customer Service Department at the number to the right side of the screen. We are here to help you.

Authorization for Release of Protected Health Information (PHI)PDF File Indicator Image

Instruction Sheet for CalOptima Health Insurance Portability and Accountability Act (HIPAA) Authorization for Release of Protected Health Information (PHI)PDF File Indicator Image

Individual Request for Protected Health Information (PHI) AccessPDF File Indicator Image

Medical Release FormPDF File Indicator Image

Member Complaint FormPDF File Indicator Image

Member Request to Amend PHIPDF File Indicator Image

Request for an Accounting of DisclosuresPDF File Indicator Image

Request for Restriction on Manner/Method of Confidential CommunicationsPDF File Indicator Image

Request for Restriction on Use and Disclosure of Protected Health Information (PHI)PDF File Indicator Image

Statement Of Disagreement Request To Include Amendment Request And Denial With Future DisclosuresPDF File Indicator Image

Suspected Fraud or Abuse Referral FormPDF File Indicator Image

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