Common Forms

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Questions

Preguntas
Câu Hỏi

For more information about PACE, please call us at:

Monday through Friday from 8 a.m. to 4:30 p.m. Pacific Time

1-714-468-1100
1-855-785-2584 (toll-free)

Persons with hearing or speech impairments can call our TDD/TTY line at
1-714-468-1063.

Or stop by our center located at:

13300 Garden Grove Blvd.
Garden Grove, CA 92843

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 PACE enrollment coordinator(s) at 1-714-468-1100 Monday through Friday from 8 a.m. to 4:30 p.m. Pacific Time. TDD/TTY users can call us at 1-714-468-1063. We are here to help you.

Use all CalOptima forms, except where they need to be PACE-specific, including:

Appeals 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

Grievance FormPDF File Indicator Image

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

PACE Referral FormPDF File Indicator Image

Suspected Fraud or Abuse Referral FormPDF File Indicator Image

Date Revised April 2, 2018

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