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Member materials and forms

Here, you’ll find the info and forms you need to get the most from your plan.


Member materials 


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


CCC Plus Member handbook ― 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)


Men and women's health brochure ― English (PDF) | Spanish (PDF)


Mental health resources for BIPOC youths (PDF)


Mental health resources for teens in the LGBTQ community (PDF)


Mental health resources for youths with disabilities (PDF)



Protected health information (PHI) release form ― English (PDF) | Spanish (PDF)


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 Native medicine (PDF)


Protected health information (PHI) access request form ― English (PDF) | Spanish (PDF)


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


Request for an Accounting of Disclosures of Protected Health Information (PHI) ― English (PDF) | Spanish (PDF)


Removal of Authorization Previously Given to Aetna ― English (PDF) | Spanish (PDF)


Fraud, waste and abuse form

Ted E. Bear, M.D., Wellness Club enrollment and incentive form ― English (PDF) | Spanish (PDF)

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