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.

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H7501_22WEB001_M (Approved 3/9/2022)

Date Revised January 21, 2022