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Common Forms

If you have questions or need help with your health care, please call our Customer Service Department at 1-714-246-8500 or toll free at 1-888-587-8088 Monday through Friday from 8 a.m. to 5:30 p.m. Pacific Time. Members with hearing or speech impairments can call our TDD/TTY line at 1-714-246-8523. We also provide interpreter services at no cost to our members. We have staff who speak your language.

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.

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Authorization for Use or Disclosure of Protected Health Information (PHI)

Authorization for Use or Disclosure of Protected Health Information (PHI) - Farsi

Authorization for Use of Disclosure of Protected Health Information (PHI) - Spanish

Authorization of Use or Disclosure of Protected Health Information (PHI) - Vietnamese

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Individual Request for Protected Health Information (PHI) Access

Individual Request for Protected Health Information (PHI) Access - Farsi

Individual Request for Protected Health Information (PHI) Access - Spanish

Individual Request for Protected Health Information (PHI) Access - Vietnamese

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Medical Release Form

Member Complaint Form

Member Complaint Form - Spanish

Member Complaint Form - Vietnamese

Member Medication Reimbursement Claim Form

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Statement Of Disagreement Request To Include Amendment Request And Denial With Future Disclosures

Suspected Fraud or Abuse Referral Form

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