Common Forms

Decorative Image
Decorative Image

Questions




For more information about OneCare Connect or to enroll, please call us at:

1-855-705-8823 (toll free)

24 hours a day/ 7 days a week.

Or visit our office Monday through Friday from 8 a.m. to 5 p.m. Pacific Time (walk-ins welcome).

Members with hearing or speech impairments can call our 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.

Common Forms

OneCare Connect Cal MediConnect Plan (Medicare-Medicaid Plan) wants to make it easier to get the health care you need. Here are forms you may use when working with OneCare Connect or your doctors. If you can’t find what you are looking for, call your Personal Care Coordinator or OneCare Connect Customer Service toll-free at 1-855-705-8823. TDD/TTY users can call 1-800-735-2929.

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

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

H8016_19MM027_M Accepted (09/25/18)

OneCare Connect Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Limitations, co-pays, and restrictions may apply. For more information, call OneCare Connect Customer Service or read the OneCare Connect Member Handbook. Benefits and/or copayments may change on January 1 of each year. Copays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details. Other Pharmacies/Physicians/Providers are available in our network. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. OneCare Connect complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. You can get this information for free in other languages. Call toll-free 1-855-705-8823. TDD/TTY users can call 1-800-735-2929. The call is free.

Download the free Adobe Reader.

Materials available on this Website in PDF format may require the free Adobe Reader to view. To download Adobe Reader for free from the Adobe Website,
click here.

Text Size