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Your Member Forms

The following forms should be sent to Samaritan Health Plans:

 Small Group Member enrollment, change & waiver: Use this form if you have a status change, such as marriage, new dependent, etc.

 Large Group Member enrollment, change & waiver: Use this form if you have a status change, such as marriage, new dependent, etc.

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

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

 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.

 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.

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

 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.

Talk with our Member Services representatives

call us at 541-768-4550 800-832-4580 TTY 800-735-2900 8 a.m. to 8 p.m.
Mon.–Fri.
or Visit our office 2300 NW Walnut Blvd. in Corvallis8 a.m. to 5 p.m. Mon.–Fri.