OneCare Connect

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 Connect.

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.

H8016_WEB023 Accepted 06/17/19

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.

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