Member forms
Skip to main content
Forms icon

Member forms


Forms

General forms

  • Advance directive form | directiva anticipada
    This form will tell your doctor and family members about the care you want to receive if you are sick or injured and cannot tell them yourself.
  • Appeals form
    A denial is a decision to not pay for a service. If you get a denial, you can appeal it using this form.
  • Complaint form | formulario de quejas
    If you are not happy with the care from your provider, you can file a complaint. You can also file a complaint if you are not happy with your service from EOCCO.

Flexible services request for health related services

Health related services are non-covered services under OHP with goals to improve the way you get care and improve your health. These services are in addition to your covered services and benefits under EOCCO. There are two kinds of health related services, flexible services and community benefit initiatives. Your provider can ask EOCCO for flexible services that can help improve your health. Some examples of flexible services that you can get are equipment, appliances, and classes. Other examples are:

  • Cooking supplies to help you make healthy meals at home
  • A gym membership for recovery if your doctor recommends it, or
  • Air purifiers to make sure the air you are breathing is clean if you have asthma or other similar conditions.

You can start the request, but your provider can help fill out the form for you. To ask for flexible services and to read our frequently asked questions, please see the EOCCO Flexible Services Request Form

Clinical Practice Guidelines

Medical Clinical Practice Guidelines are available upon request. Please contact EOCCO Customer Service for more information.

Pharmacy forms

Questions?

Customer Service: 888-788-9821 (TTY users: 711)
Hours: Monday through Friday, 7:30 a.m. to 5:30 p.m. PST

EOCCO members should have their member ID number ready for quicker help.

See more options