Resources and Forms - Ventura County Health Care Plan

English

Authorization to Release Information Form

Coordination of Benefits Form

Grievance and Appeal Online Form

Grievance and Appeal PDF Form

Grievance and Appeal for Cancellation, Rescissions, & Non-Renewals of an Enrollment Subscription PDF Form

HIPAA Letter and Notice of Privacy Practices

Member Language and Ethnicity Questionnaire

Optum Behavioral Health Release of Information

Out-of-Pocket Maximum Notices

Reimbursement Claim Form

Reimbursement Claim Form – At-Home COVID Test

Request Case Management or Disease Management Online Form

Español

Forma de Autorización para Divulgar Información

Formulario de la red para Quejas y Apelaciónes

Forma para Quejas y Apelaciónes

Encuesta del Idioma para el Miembro