Documents & Forms
Member documents in one place
It’s important for members to have what they need to receive quality coordinated health care. If you need help with a form or in another language, large print, Braille, or a format you prefer, please call our customer service line at 1-855-722-8205 (TTY 711). This help is free.
Member Materials
Member Language Access Toolkit
Being able to talk to your doctor in your language is important.
This toolkit will let you know:
- your legal rights and,
- what language services you can get as a YCCO member.
Member Policies
Below is a list of the policies available to you as a member of YCCO.
- Care Coordination & Transition of Care Policy
- Advance Directives Policy
- Grievance System Policy
- Member Complaints and Grievances Policy
- Denials, Appeals and Contested Case Hearings Policy
- Health Related Services Policy
Member Forms
Below is a list of some of the most common forms used by members.
Click on the links to open the forms in PDF format.
- Authorization to Release or Share Personal Health Information (PHI) Forms
YCCO Authorization to Use and Disclosure Protected Health Information (English)
Autorización de YCCO para el uso y divulgación de información médica protegida (español) - Appeal and Hearing Forms
OHP 3302 Appeal and Hearing Request
OHP 3302 Solicitud de apelación y audiencia
OHP 3302 طلب الاستئناف وجلسة الاستماع
OHP 3302 Racfaanka iyo Codsiga Maqalka
OHP 3302 Апелляция и ходатайство о проведении слушания
OHP 3302 Yêu cầu kháng cáo và điều trần - Administrative Hearing Request Forms
Administrative Hearing Request
Solicitud de Audiencia Administrativa - Complaint Forms
YCCO Complaint Form
YCCO Formulario de reclamación (Spanish)
Complaint Form (English) for OHP Complaints
Formulario de queja para quejas de OHP (Spanish) - Non-Discrimination Notice (NDN)
Yamhill Community Care Non-Discrimination Notice (English) & Yamhill Community Care Non-Discrimination Notice (English Large Print)
Aviso de no discriminación de Yamhill Community Care & Aviso de no discriminación de Yamhill Community Care Letra grande
Bulshada daryeelkaYamhill maTakooro (Somali)
Yamhill Community Care Non-Discrimination Notice (Dari/Persian) - Advance Directives in multiple languages
Advance Directive - Declaration for Mental Health Treatment
Declaration for Mental Health Treatment (English)
Declaración para el tratamiento de la salud mental (Spanish) - Barrier Information: Use the Barrier Submission Form to report any barriers families may be experiencing in receiving wraparound services. Reports will be reviewed by a practice workgroup who will work to identify solutions to barriers. Learn more about the barrier resolution process by viewing the Barrier Resolution Process Diagram.
Health Surveys
After you enroll with YCCO we mail you a survey about your health. The survey asks questions about your general health with the goal of helping reduce health risks, maintain health, and prevent disease.
As part of your care team, please tell us how we can support your health. Complete the following survey questions. You can complete the survey by mail or phone.
Return the survey in the envelope we sent, no stamp is needed. We will accept your HRA by mail or fax.
Mail: YCCO Health Survey, PO Box 5490, Salem, OR 97304
Fax: 503-607-8336
If you want an HRA sent to you, or you want one in your preferred language, large print, or in another format call Customer Service to request one, you can reach them at 855-722-8502 or TTY 711. You can also make your request by emailing us one of these two ways:
- Care Management: caremanagement@yamhillcco.org
- YCCO: info@yamhillcco.org
Care Management is your point of contact for care coordination needs, and a care manager is available to you and may call you. You can reach Care Management at 971-345-5932 or 833-257-2191 (TTY: 711).
English Health Survey:
Encuesta de Salud en Español:
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