F O R A L L P L A N S Prior authorization: Request prior authorization for services. See Medical Management for current prior authorization lists for all plans. Imaging authorization: Request prior authorization for imaging services. Rx exception/prior authorization: Request exception to prescription drug coverage rules. Samaritan InterCommunity Health Network (IHN) IHN-PCP100 - Request form for member to change PCP DMAP 741 Hysterectomy Consent DMAP 741 Hysterectomy Consent: Spanish DMAP 742A Consent to Sterilization-Adult DMAP 742A Consent to Sterilization-Spanish Adult DMAP 742B-Consent to Sterilization-Minor DMAP 742B Consent to Sterilization-Spanish Minor Samaritan Choice Plans Disabled Dependent Determination: Fax or mail to Samaritan Choice Plans’ for the Medical Director to review and determine patient disability. Fax Rx for MAIL ORDER: Transfer member prescription drugs to Samaritan Health Services Pharmacy for mail order. Samaritan Advantage Health Plan HMO Fax Rx for MAIL ORDER: Transfer member prescription drugs to Samaritan Health Services Pharmacy for mail order. Medicare Part D Coverage Determination Request Form: Request Medicare Part D prescription drug coverage determination. Samaritan Healthy KidsConnect Fax Rx for MAIL ORDER: Transfer member prescription drugs to Samaritan Health Services Pharmacy for mail order. COHO Benefits of CTSI There currently are no forms specifically for COHO providers to use at this time. Please see forms created and available that are appropriate to use for All Plans.
Back to top
Register for He@lthWeb: get 24/7 online access to Samaritan Health Plans' eligibility and claims information Login to He@lthWeb: for registered users VIEW He@lthWeb tutorial Samaritan InterCommunity Health Network (IHN)-State DMAP MMIS web portal
Samaritan Advantage Health Plan HMO; for enrollment information, visit our Medicare section Samaritan Choice Plans Samaritan InterCommunity Health Network (IHN) Samaritan Healthy KidsConnect COHO Benefits of CTSI
Training request form
Samaritan Health Plans offer Provider Directories that make referring and collaboration of care much easier for you and your staff. Below, Provider Directories are listed by plan for your convenience. Samaritan Advantage Health Plan HMO (Medicare) Primary Care Provider Directory Specialties Directory
Samaritan Choice Plans (Samaritan employee plan) Primary Care Provider Directory Specialties Directory
Samaritan InterCommunity Health Network (IHN) (Oregon Health Plan) Primary Care Provider Directory Specialties Directory Samaritan Healthy KidsConnect Primary Care Provider Directory Specialties Directory COHO (Confederated Tribes of Siletz Indians’ members and employees) Provider Directory
L I N K I N G T O O T H E R R E S O U R C E S : Medicare CMS Medicare Manuals CMS home Social Security Administration Senior Health Insurance Benefits Assistance Program (SHIBA) Oregon Health Plan (Medicaid) Division of of Medical Assistance Programs (DMAP) Fee Schedule DMAP Prescription Drug Plan Oregon Administrative Rules Oregon Health Plan (OHP) Member Benefit Guide OHP Prioritized List currently covers lines 502 and above OHP Provider Tools Oregon Healthy Kids Oregon Healthy Kids Office of Private Health Partnerships Oregon Health Authority Oregon Insurance Division Department of Human Services
COHO - Confederated Tribes of Siletz Indians' members and employees DMAP - Division of Medical Assistance Programs IHN - Samaritan InterCommunity Health Network OHP - Oregon Health Plan SAHP - Samaritan Advantage Health Plan HMO SCP - Samaritan Choice Plans
(Health Insurance Portability and Accountability Act) View policy