Provider Forms
Keep Your Information Current
Be sure to keep your practice information current to ensure timely payment and accurate listing in our provider directory. You can add or remove a provider from your group and update panel availability and provider information.
Access Plan Forms
Samaritan Advantage HMO Plans - Conventional, Premier, Premier Plus & Special Needs Plans
You have the option to submit authorizations online through your provider portal, Provider Connect.
Appeal request form
Case Management Referral Form
Hepatitis C Therapy Prior Authorization Form
Medication Redetermination Form
Member Request to Change PCP Form
Prescription Mail Order Transfer Form - to transfer member prescription drugs to Samaritan Health Services Pharmacy for mail order
Prior Authorization Form
Prior Authorization Form Instructions
Rx Exception/Prior Authorization Form
Waiver of Liability Statement – Non-contracted providers must include a signed Waiver of Liability form holding the enrollee harmless in order to request a reconsideration of the plan’s denial of payment. The reconsideration must be filed within 60 calendar days from the remittance notification.
Samaritan Employer Groups Plans - Standard, Performance, Everyday Choices, and Momentum
You have the option to submit authorizations online through your provider portal, Provider Connect.
Prior Authorization Form
Prior Authorization Form Instructions
Rx Exception/Prior Authorization Form
Hepatitis C Therapy Prior Authorization Form
Appeal Request Form
Samaritan Choice Plans for Employees of Samaritan Health Services
You have the option to submit authorizations online through your provider portal, Provider Connect.
Prior Authorization Form
Prior Authorization Form Instructions
Rx Exception/Prior Authorization Form
Hepatitis C Therapy Prior Authorization Form
Disabled Dependent Determination Form
Prescription Mail Order Transfer Form - to transfer member prescription drugs to Samaritan Health Services Pharmacy for mail order
SamFit/SAM Physical Therapy Reimbursement Request Form
Appeal Request Form
You have the option to submit authorizations online through your provider portal, Provider Connect
Care Coordination Request Form
Individual Flexible Service Request Form (Request health-related services that OHP does not cover. Review the flexible services instructions.)
Prior Authorization Form
Prior Authorization Form Instructions
Rx Exception/Prior Authorization Form
Hepatitis C Therapy Prior Authorization Form
Case Management Referral Form
Member Request to Change PCP Form
Appeal Request Form
Opioid Tapering Plan Form
Find a Document
Can’t find what you’re looking for? Search our document library.
Provider Prescription Prior Authorization Requests
Select medications may require prior authorization. A physician may submit authorization requests by:
- Faxing the plan using the form below.
- Submit electronically using one of our partners below (CoverMyMeds or Surescripts).
You can call Customer Service for additional questions at 541-768-5207 or toll free at 888-435-2396.
Prescription Prior Authorization FormSubmit Authorization to CoverMyMedsSubmit Authorization to Surescripts