Member Forms
GRIEVANCE FORM
If you would like to file a grievance with CalViva Health, click here.
Confidential Communications Request Forms
Required if you would like to have CalViva Health send any communication that has protected health information (PHI) directly to you instead of the primary account holder.
If you would like to submit a request for confidential communications, click here.
You may also use this English Confidential Communications Request Form, Spanish Confidential Communications Request Form or Hmong Confidential Communications Request Form and mail it to the address found at the bottom of the form.
If you would like to revoke your submitted request for confidential communications, click here.
You may also use this English Revocation Printable Form, Spanish Revocation Printable Form, or Hmong Revocation Printable Form and mail it to the address found at the bottom of the form.
Authorization for Disclosure of PHI
Required for the use or disclosure of your protected health information (PHI) beyond uses and disclosures for payment, treatment or health care operations.
If you would like to submit an online authorization to disclose your PHI form, click here.
You may also use this English Authorization Printable Form, Spanish Authorization Printable Form, or Hmong Authorization Printable Form and mail it to the address found at the bottom of the form.
If you would like to revoke your submitted authorization to disclose PHI form, click here.
You may also use this English Revocation Printable Form, Spanish Revocation Printable Form, or Hmong Revocation Printable Form and mail it to the address found at the bottom of the form..
Health Information Form
The Health Information Form will help your Primacy Care Physician (PCP) identify any extra needs or services you may require. Please share this form with your PCP upon completion.