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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.

Member Termination: This is required to process your disenrollment from your plan.

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.