Common Forms

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Questions

Preguntas
Câu Hỏi

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

1-877-412-2734 (toll free)
1-714-246-8711 (fax)

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.

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 aren't sure which one you need, please call our Customer Service Department at the number on the right side of the screen. We are here to help you.

Appeals and Grievance FormPDF File Indicator Image

Appointment of Representative FormPDF File Indicator Image

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

Enrollment FormPDF File Indicator Image

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

Member Request to Amend Protected Health Information (PHI)PDF File Indicator Image

Prescription Drugs Payment Request FormPDF 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 PDF File Indicator Image

Suspected Fraud or Abuse Referral FormPDF File Indicator Image

Date Revised May 31, 2017

To file a complaint with Medicare, click on the following link to complete a complaint form on the Medicare website: Medicare Complaint Form.

H5433_WEB1004 Approved (11/15/16)

OneCare (HMO SNP) is a Medicare Advantage organization with a Medicare contract. Enrollment in OneCare depends on contract renewal. Eligible beneficiaries can enroll at any time. Eligible beneficiaries must have Part A and Part B to enroll in the plan. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. Co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. Other Pharmacies/Physicians/Providers are available in our network. Medicare beneficiaries may also enroll in OneCare (HMO SNP) through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. Medicare has neither reviewed nor endorsed this information. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. OneCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This information is available for free in other languages. Please call our customer service number at 1-877-412-2734, 24 hours a day, 7 days a week. TDD/TTY users should call 1-800-735-2929.

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