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Select a category below to find the form you need.

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

 Appeal Request Form: This form can be used to request an appeal of a medical care coverage decision made by our plan.

 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.

 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.  

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

Prior Authorization Request Form: This form can be used by your provider to request a service or item that needs prior authorization by our plan.

Request Recurring Electronic Funds Transfer (EFT) service or One Time Electronic Funds Transfer (EFT) service: You have the option of paying your monthly premium through automatic withdrawal from your credit / debit card OR personal bank account.

 Request for Health Plan Records: To speed up your request, this form is required by the plan to be completed when you are requesting any Health Plan documentation from us.

 Request reimbursement for medical or dental services: This form can be used to request reimbursement from our plan for covered medical or dental services that you have paid for out-of-pocket.

Medication Exception/Prior Authorization Form: If you are a provider, you can use this form to ask us to make a coverage determination for a prior authorized medication or a medication exception to our coverage rules if the member is on one of our plans that offer prescription drug coverage.

 Redetermination Request Form: If we deny your request for coverage of (or payment for) a prescription drugs, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination. This form may be sent to us by mail or fax:

  • Address: Samaritan Advantage Health Plan HMO , P.O. Box 1310, Corvallis, OR 97339
  • Fax Number: 541-768-9765
  • Expedited redeterminations (appeals) requests can by made by phone at 541-768-4550 or toll free at 1-800-832-4580.

 Prescription Mail Order: Use this form when you have a written prescription that you are mailing to Samaritan Health Services.

 Samaritan Pharmacy Services FAX Order Form: Provide this form to your physician to fax your prescription to Samaritan Health Services.

 Samaritan Pharmacy Services Prescription Transfer Request: Use this form to conveniently transfer all your prescriptions to Samaritan Health Services. We will contact the pharmacies you list on the form for you and have the prescriptions transferred.

 Prescription Reimbursement Form: We will cover your prescription at an out-of-network pharmacy under certain conditions.

You have the right to name a person to direct your health care when you cannot do so. This person is called your “health care representative.” To appoint a representative for your Medicare benefits, both you and your representative must sign, date and complete one of these forms:

You must send a copy to Samaritan Advantage Health Plan HMO each time you want the appointed representative to head any of your appeal requests within 60 days of the initial denial for the service requested. Once the form is received by Samaritan Advantage Health Plan HMO, it is considered current for one year. After one year has passed, you must complete a new form if you would like to continue the appointment of that representative.

We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 800-832-4580. Someone who speaks your language can help you. This is a free service.

Page updated 10/29/2019