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Part D Coverage Resource

  • Forms

Authorization Service Request (Spanish)

  • Document
  • Forms

Authorization Service Request (English)

  • Document
  • Forms

Authorization for Disclosure of Protected Health Information (Spanish)

  • Document
  • Forms

Authorization for Disclosure of Protected Health Information (English)

  • Document
  • Forms, Plan Documents

Dental Fee Schedule

Champion Health Plan Dental Fee Schedule – California and Nevada (English)
  • Document
  • Forms

MedImpact Direct Mail Order Prescription Drug Forms (English)

  • Document
  • Forms

Prescription Drug Claim Form (Spanish)

  • Document
  • Forms, Plan Resources

Prescription Drug Claim Form (English)

To submit a Healthcare Claim or Bill, please complete the form and submit the form and receipt(s) to: MedImpact Healthcare Systems, Inc. PO Box 509108 San Diego, CA 92150-9108 Fax: 858-549-1569 E-mail: Claims@Medimpact.com”
  • Document
  • Forms

Complaint & Appeal Form (Spanish)

  • Document
  • Forms

Complaint & Appeal Form (English)

  • Document