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The following forms should be sent to Samaritan Health Plans:

Accident/Injury Report: Use this form to report information regarding an accident or injury for claim processing.

 Appeal Request: Use this form if you intend to appeal a benefit coverage decision made by Samaritan Health Plans.

 Authorization for Verbal Communication: Use this form to confirm permission for Samaritan Choice Plans to discuss or disclose your health care or payment for your health care.

 Authorized Representative: Use this form to confirm permission for Samaritan Health Plans to discuss or disclose your protected health information to a particular person who acts as your Authorized Representative.

 Authorization to Disclose Health Information: Use this form to confirm permission for Samaritan Health Plans to discuss or disclose your protected health information to a particular individual or entity.  

 Coordination of Benefits: To properly process your claims, Samaritan Health Plans needs periodic updates regarding your other health insurance coverage.

 Disabled Dependent Certification: Request continuance of coverage for a dependent that is reaching the limiting age of coverage.

 Medication Exception: Request a medication exception to Samaritan Health Plans’ coverage rules, e.g., covering your drug even if it is not on the formulary, waiving coverage restrictions or limits on your drug, or providing a higher level of coverage for your drug.

 Medical Reimbursement Claim: Request reimbursement for services that you have received and paid for that are a covered benefit.

 Member Request for Health Plan Records: You are required to complete and send this form to Samaritan Health Plans at the address indicated when requesting any documentation from Samaritan Health Plans.

 Member Request to Access or Share Health Information: Request the sharing of your health care records and what information may be shared.

 Prescription Reimbursement Claim: Request reimbursement for prescriptions obtained at a non-participating pharmacy.