Member materials and forms

Member materials 

Medallion (Medicaid)/FAMIS Member handbook ― English (PDF) | Spanish (PDF)

CCC Plus Member handbook ― English (PDF) | Spanish (PDF)

Member Vaccine Incentive Letter Form ― English (PDF) | Spanish (PDF)

Diabetes wellness exam flyer ― English (PDF) | Spanish (PDF)

Transitioning from Pediatrics to Primary Care Flyer ― English (PDF) | Spanish (PDF)

Well Woman Exams Flyer ― English (PDF) | Spanish (PDF)

Men's Health Exams Flyer ― English (PDF) | Spanish (PDF)

EPSDT Member Tip Sheet: Birth to 3 years ― English (PDF) | Spanish (PDF)

EPSDT Member Tip Sheet: Ages 3 to 21 years ― English (PDF) | Spanish (PDF)

Forms 

Nursing facility transition brochure (PDF)

Maternity Incentive Program form ― English (PDF) | Spanish (PDF)

Important information regarding PPL (Public Partnerships, LLC) (PDF)

Member reimbursement request form for non-traditional Indian medicine (PDF)

Authorization to release protected health information (PHI) ― English (PDF) | Spanish (PDF)

Authorization to release psychotherapy notes ― English (PDF) | Spanish (PDF)

Fraud, waste and abuse form