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Samaritan Choice Forms 

The following forms should be sent to Samaritan Choice Plans:

Accident/Injury Report: Use this form to report information regarding an accident or injury for claim processing.

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

Authorization for Verbal Communication: Use this form to grant us permission to speak with someone else regarding your benefits, claims or other health information.

Authorization to Disclose Health Information: Use this form if you are someone other than the member (or their legal representative) and need to request a copy of our member’s record for which the member’s authorization is required.

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 to Access or Share Health Information: Use this form to request a copy of your health plan record, or direct us to send it to a third party of your choosing.

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

Samaritan Human Resources Department Forms

The following form needs 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.

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 SHP.

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.
or Visit our office 2300 NW Walnut Blvd. in Corvallis8 a.m. to 5 p.m. Mon.–Fri.