OneCare (HMO SNP)

Common Forms

Authorizations, requests and more

Appeals and Grievance Form Download PDF Icon Use this form to request a decision appeal, or to file a formal complaint.

Appointment of Representative Form Download PDF Icon Use this form to appoint a person to act for you about your appeal or rights

Authorization for Release of Protected Health Information (PHI) Download PDF Icon Use this form to authorize CalOptima to release your protected health information (PHI) to another person or organization. See next item below, on how to complete this form.

Enrollment Form Download PDF Icon Use this form to apply for OneCare (HMO SNP).

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).

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.

Prescription Drugs Payment Request Form Download PDF Icon Use this form to pay you back for our share of the cost of a drug.

Request for an Accounting of Disclosure 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 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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To file a complaint with Medicare, click on the following link to complete a complaint form on the Medicare website: Medicare Complaint Form.

H5433_WEB020_M Accepted 06/17/19

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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