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Download plan documents and forms to help you serve your clients interested in our Samaritan Advantage plans. Can’t find something? Contact us to let us know what you need.

Enrollment Documents

Pre-enrollment Checklist
Enrollment Form Instructions
2019 Enrollment Form
Scope of Appointment Form

Completed forms may be faxed directly to our Enrollment Department at 541-768-9778. Only Conventional Plan applications require premium payment upon submission.

It is expected that the agent’s received date(s) for the completed enrollment form and completed scope of appointment form each be documented on the forms in order to be compliant.

2019 Plan Documents

Benefit Highlights — Premier Plans
Benefit Highlights — Conventional Plans
Extra Help
Prior Authorization List
Summary of Benefits
Nondiscrimination Notice
Multi-Language Interpreter Services
Star Ratings

Want to Learn More About Our Medicare Plans?

Our Medicare Advantage plans offer comprehensive dental benefits, gym memberships to SamFit and more. Visit our Medicare website to find out more.