Member documents in one place
It’s important for members to have what they need receive quality coordinated health care. If you need help with a form, please call our customer service line 1-855-722-8205 (TTY 711)!
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
Care Coordination & Transition of Care Policy - Advance Directives
Advance Directives Policy - Grievance System
Grievance System 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 Disclosure Auth (English)
YCCO Disclosure Auth (Spanish) YCCO Information Sharing Authorization Form - Appeal and Hearing Forms
Appeal & Hearing Form
Request to Review a Health Care Decision OHP 3302
Hearing Form
https://sharedsystems.dhsoha.state.or.us/DHSForms/Served/me0443.pdf - Complaint Forms YCCO Complaint Form YCCO Complaint Form (Spanish)
Complaint Form (English) for OHP Complaints
Complaint Form (Spanish) for OHP Complaints - Health Related Social Needs
- Non-Discrimination Notice (NDN)
Yamhill Community Care Non-Discrimination Notice (English) & Yamhill Community Care Non-Discrimination Notice (English Large Print)
Yamhill Community Care Non-Discrimination Notice (Spanish) & Yamhill Community Care Non-Discrimination Notice (Spanish Large Print) - Advance Directives in multiple languages
Advance Directive - Declaration for Mental Health Treatment
Declaration for Mental Health Treatment (English)
Declaration for Mental Health Treatment (Spanish) - Barrier Information Barrier Submission Form
- Use this 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.
Health Surveys
Shortly after you enroll, YCCO will 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. You can also fax it to us at the fax number below. Care Management is your point of contact for care coordination needs and a care manager is available to you and may call you.
Mail: YCCO Health Survey: PO Box 5490, Salem, OR 97304
Phone: 971-345-5932 or 833-257-2191 or TTY: 711
Fax: 503-607-8336
Email: caremanagement@yamhillcco.org
English Health Surveys:
- YCCO HRA Survey_Adult New Member
- YCCO HRA Survey_Adult New Member Large Print
- YCCO HRA Survey_Adult Current Member
- YCCO HRA Survey_Adult Current Member Large Print
- YCCO HRA Survey Ages 0-1
- YCCO HRA Survey Ages 0-1 Large Print
- YCCO HRA Survey Ages 1-5
- YCCO HRA Survey Ages 1-5 Large Print
- YCCO HRA Survey Ages 6-11
- YCCO HRA Survey Ages 6-11 Large Print
- YCCO HRA Survey Ages 12-17
- YCCO HRA Survey Ages 12-17 Large Print
Encuestas de Salud en Español:
- YCCO HRA Encuesta Nuevo Miembro Adulto Letra Grande
- YCCO HRA Encuesta Adulto Miembro Actual Letra Grande
- YCCO HRA Encuesta Edades 0-1 Letra Grande
- YCCO HRA Encuesta Edades 1-5 Letra Grande
- YCCO HRA Encuesta Edades 6-11Letra Grande
- YCCO HRA Encuesta Edades 12-17 Letra Grande
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