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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)

 

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)

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

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