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Download Forms & Resources for Your Clients

Access and download forms and resources for your clients. Don’t hesitate to contact us if you need assistance.

Enrollment Documents

Pre-enrollment Checklist
Enrollment Form Instructions
2022 Enrollment Form
Scope of Appointment Form

Completed forms may be faxed directly to our Enrollment Department at 541-768-9778 or emailed to SHPOMemberEnrollment@samhealth.org.

It is expected that the agent’s received date(s) for the completed enrollment form and completed scope of appointment form each be documented on the forms in order to be compliant.

2022 Plan Documents

You can download Medicare Advantage plan documents. The following plan documents are available to help you serve your clients interested in our Samaritan Advantage plans and can be used to complete an enrollment information kit:

2022 Plans Overview
2022 Low Income Subsidy Premium Summary
2022 Summary of Benefits - Conventional, Premier & Premier Plus Plan
2022 Prior Authorization List
2022 Over-the-Counter Drug List
Nondiscrimination Notice
Multi-Language Interpreter Services
2022 Star Ratings
24/7 Nurse Line

Looking for a Dentist?

To find a dental provider, choose any dental provider who has not opted-out of participating in Medicare programs. Review CMS Opt-Out List.

Find a Document

Can’t find what you’re looking for?  Search our document library.