Member documents in one place
It’s important for members to have what they need recieve 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
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
Appeal and Hearing Request for Medical Service Denials (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)
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