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Samaritan Choice Forms 

The following forms should be sent to Samaritan Choice Plans:

Appeal Request: Use this form if you intend to appeal a benefit coverage decision made by Samaritan Choice Plans.

Authorized Representative Form: Use this form to confirm permission for Samaritan Choice Plans to discuss or disclose your protected health information to a particular person who acts as your Authorized Representative.

Coordination of Benefits: To properly process your claims, Samaritan Choice Plans needs periodic updates regarding your other health insurance coverage. More information on double coverage.

Disabled Dependent Certification: Request continuance of coverage for a dependent that is reaching the limiting age of coverage.

Medical reimbursement claim: Request reimbursement for services that you have received and paid for that are a covered benefit.

Medication Exception: Request medication exception to Samaritan Choice 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.

Member Request for Health Plan Records Form: You are required to complete and send this form to the Health Plan at the address indicated when requesting any documentation from Samaritan Choice Plans.

Prescription Mail Order Form: Use this form when you have a written prescription that you are mailing from a Samaritan Health Services pharmacy.

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

Samaritan Human Resources Department Forms

The following forms need to be turned into your local Samaritan Human Resources Department for approval:

Affidavit of Domestic Partnership: Add a person to the health plan as a Domestic Partner if criteria have been met.

Declination of Coverage: Samaritan offers an additional amount in each paycheck to employees who decline health plan coverage even though they are eligible. The amount of the additional income is determined by Samaritan each year. To decline coverage, you must complete and submit this form within 30 days of the close of open enrollment each year. You must be able to provide proof of other coverage.

COBRA Continuation Coverage

Address notification: Report a change of address for yourself or any covered dependent that receives mail at an address different from yours. If you are a current employee, please remember to also update your information in PeopleSoft. 

Qualifying event or extension notification: You are required to report certain events that occur while you or your dependents are on COBRA continuation coverage. Complete this form and follow the instructions to provide the required information and documentation to SHPO.

Continuation coverage election: After you have received an Election Notice, use this form to elect COBRA continuation coverage for yourself or another qualified beneficiary.

COBRA drop coverage or early termination: After you have elected COBRA continuation coverage, use this form to list members that need some or all coverage dropped. 

COBRA recurring credit card payments: After you have elected COBRA continuation coverage, use this form to setup recurring credit card payments for your COBRA monthly premiums.

 

Talk with our Member Services representatives

call us at 541-768-4550 800-832-4580 TTY 800-735-2900 8 a.m. to 8 p.m.
Mon.–Fri.
or Visit our office 2300 NW Walnut Blvd. in Corvallis8 a.m. to 5 p.m. Mon.–Fri.