Forms

Counties Served:

California: Fresno, Los Angeles, Madera, Orange, Riverside, San Bernardino, and San Diego
Nevada: Churchill, Clark, Carson City, and Washoe

Select your state:

California

Nevada

California

Authorization Service Request

Complaint & Appeal Form

Appointment of Representation

Authorization for Disclosure of Protected Health Information

Enrollment Form

MedImpact Direct Mail Order Prescription Drug Forms

Covered Medication List (Formulary)

Prescription Drug Claim Form

Health Risk Assessment

Bridge Case Management Form

Transportation Reimbursement Form

Scope of Appointment Form

This page was last updated on 2/16/24. Pending CMS approval.

Members

Legal

Contact Us

Administrative Office
19700 Fairchild Rd, Suite 230
Irvine, CA 92612

Mailing Address
Champion Health Plan
PO Box 15337
Long Beach, CA 90815-9995

1-800-885-8000 | TTY 711

Member Services Hours of Operation

April 1 – September 30:
Monday – Friday, 8 am – 8 pm
October 1 – March 31:
Monday – Sunday, 8 am – 8 pm

Champion Health Plan of California, Inc. and Renal Payer Solutions, Inc. dba Champion Health Plan of Nevada, collectively referred to as “Champion Health Plan.”

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