Medi-Cal

Common Forms

Authorizations, requests and more

Authorization for Release of Protected Health Information (PHI) Access Download PDF Icon Use this form to authorize CalOptima to release your protected health information (PHI) to another person or organization.

Individual Request for Protected Health Information (PHI) Access  Download PDF Icon CalOptima members, past and current, can use this form to request copies of their protected health information (PHI).

Medical Release Form Download PDF Icon If you have changed doctors, fill out and return this form to your new doctor’s office if you would like your new doctor to have your medical records from your last doctor.

Member Request to Amend Protected Health Information (PHI) Download PDF Icon If you believe part of your Protected Health Information (PHI) is not correct, use this form to request a change.

Request for an Accounting of Disclosures Download PDF Icon Use this form to request a record of how your Protected Health Information (PHI) was disclosed by CalOptima.

Request for Restriction on Manner/Method of Confidential Communications Download PDF Icon Use this form if you would like to request to receive confidential communications of Protected Health Information (PHI) by different ways or to a different address.

Request for Restriction on Use and Disclosure of Protected Health Information (PHI)  Download PDF Icon Use this form if you would like to request that CalOptima limit the disclosure of parts of your Protected Health Information to certain persons or organizations.

Statement Of Disagreement Request To Include Amendment Request And Denial With Future Disclosures Download PDF Icon If you requested to change your Protected Health Information (PHI) and CalOptima denied your request, you may use this form to request that CalOptima include the request and denial in future disclosures of your PHI.

Suspected Fraud or Abuse Referral Form Download PDF Icon Use this form to report suspected fraud or abuse. You do not have to give your name to report suspected fraud or abuse.

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