PACE

Common Forms

Authorizations, requests and more

Appeal for Reconsideration of Denial Download PDF Icon Use this PACE form, to appeal a denial

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 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.

Compliance and Fraud, Waste and Abuse Reporting Form Download PDF Icon Use this form to report a suspected non-compliance issue or fraud, waste and abuse (FWA). The confidential form has instructions on how to fill it out and where to send it. You do not have to give your name to report suspected fraud or abuse.

Grievance Form Download PDF Icon Use this PACE form to file a grievance.

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).

Revocation of Authorization for Release of Protected Health Information Download PDF Icon Use this form if you would like to revoke, withdraw, and stop an authorization you gave to CalOptima to disclose your Protected Health Information (PHI) to a previously authorized recipient.

PACE Referral Form Download PDF Icon Use this form to refer someone to PACE.

Contact Us
  • PACE Customer Service
    You can contact us Monday through Friday from 8 a.m. to 4:30 p.m.
    1-714-468-1100 Local
    1-855-785-2584 Toll-free
    1-714-468-1063 TDD/TTY

  • Sign Up for PACE
    1-714-468-1100 Local
    Enrollment information
Visit Us
  • We are continuing to serve our members through our Customer Service phone numbers, as we adhere to guidelines to reduce the possibility of COVID-19 transmission. Our buildings are closed to visitors.

  • We speak your language
    Request interpreter services
New PACE Members
Forms and Documents

Download the free Adobe Reader.

Materials available on this website in PDF format may require the free Adobe Reader to view. To download Adobe Reader for free from the Adobe website, click here.

H7501_WEB015_M Approved 8/22/19

Date Revised August 23, 2019