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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
2020 Enrollment Form
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.

2020 Plan Documents

2020 Plan Comparison Guide
2020 Extra Help
2020 Summary of Benefits
2020 Prior Authorization List
Nondiscrimination Notice
Multi-Language Interpreter Services
Star Ratings
24/7 Nurse Line
Provider Directory (To find a dental provider, choose any dental provider who has not opted-out of participating in Medicare programs. Review CMS Opt-Out List.)
All 2020 plan documents

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
24/7 Nurse Line

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.