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Member Forms

GRIEVANCE FORM

If you would like to file a grievance with CalViva Health, click here.

Confidential Communications Request Forms

View the request forms here.

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.

Authorization for Disclosure of PHI

Download the 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.

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.

Download the Health Information Form (English).

For Spanish, click here.

For Hmong, click here.