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!
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
Care Coordination Policy - Advance Directives
Advance Directives
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.
- Barrier InformationBarrier 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.
Barrier Resolution Process Diagram
- Learn more about the barrier resolution process.
- Authorization to Release Personal Health Information (PHI) Form
YCCO Disclosure Auth (English)
YCCO Disclosure Auth (Spanish) - 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
Complaint Form (English)
Complaint Form (Spanish) - Non-Discrimination Notice (NDN)
Yamhill Community Care Non-Discrimination Notice (English)
Yamhill Community Care Non-Discrimination Notice (Spanish) - Advance Directives
Advance Directive (English)
Advanced Directive (Spanish) - Declaration for Mental Health Treatment
Declaration for Mental Health Treatment (English)
Declaration for Mental Health Treatment (Spanish)
Health Surveys
Shortly after you enroll, YCCO will mail you a survey about your health. This survey is called a Health Risk Screening.
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. 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: 503-574-7247 or TTY: 711
Health Surveys:
- YCCO HRA Survey_Adult New Member
- YCCO HRA Survey_Adult Current Member
- YCCO HRA Survey Ages 0-1
- YCCO HRA Survey Ages 1-5
- YCCO HRA Survey Ages 6-11
- YCCO HRA Survey Ages 12-17
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Click to download the free Adobe Reader program.
