Your Member Forms – Employer Group

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 grant us permission to speak with someone else regarding your benefits, claims or other health information.

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.

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

Record Request Form: Use this form if you are someone other than the member (or their legal representative) and need to request a copy of our member’s record for which the member’s authorization is required.