Forms
Credentialing Forms
General forms
- Advance Directive
- Alcohol and/or Drug Dependence Screening - Adults & Adolescents
- Behavioral Health Treatment Plan--Psychiatrist/PMHNP
- Behavioral Health Treatment Plan--Therapist
- Medical/Vision CMS (formerly HCFA) 1500 Claim
- Material Risk Notice
- Prenatal/Postpartum fax
- Provider Refund Submission
- PHQ-9 | Scoring instructions
- Referral/Authorization
- Rx Preauthorization
- Treatment Plan
Oregon Health Plan Forms
- Acupuncture Referral Request
- Bariatric Surgery Evaluation
- CMS (formerly HCFA) 1500 | Instructions
- Chemical Dependency Authorization Denial
- Drug Free Treatment Authorization Request (TAR)
- HIPAA Release
- Hysterectomy Consent
- Interpreter Request
- Patient Responsibility Waiver
- PCP Change
- Rx Preauthorization
- Referral/Authorization
- Sterilization Consent
- Sterilization Consent for 15-20 years old
- Synthetic Opiate Treatment Services Change in Client Status Information
- Synthetic Opiate Treatment Authorization Request
To improve coordination of care between PCPs and Mental Health Providers for Southern Oregon residents, the Mind Body Connection (MBC) collaborative was established in 2005. MBC created a Notice of Referral/Consent For the Release of Information form for OHP members. This form exists to enhance communication of vital information between mental and physical health care providers via a legal release of information signed by the patient, parent or legal guardian. ODS partners with Family Care and Mid Rogue Health Plan to distribute this tool to providers in Jackson County. Please use this new form with all OHP patients in Jackson County. You may download the form and checklist using the links below.
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Check benefits and eligibility
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