Your Forms

You or Your Provider May Need These Coverage-related Forms

Accident/Injury Report Use this form to report information regarding an accident or injury for claim processing.
Appeal Request Form Ask IHN-CCO to change a decision made about your medical coverage.
Authorization for Verbal Communication Form  Use this form to confirm permission for IHN-CCO to discuss or disclose your health care or payment for your health care.
Authorized Representative Form

You have the right to choose an Authorized Representative. This person has your permission to discuss your health information with IHN-CCO.
Authorization to Disclose Health Information Form

Use this form to confirm permission for IHN-CCO to discuss or disclose your protected health information to a particular individual or entity.  
Dental Plan Choice Card Choose or change your dental plan.
Flexible Services Request Form Request health-related services that OHP does not cover. Review flexible services instructions.
Hearing Request Form Request an administrative hearing from the Department of Medical Assistance Programs (DMAP).
Medication Exception Request medically necessary medications that are not normally covered on our formulary. Or request medications that request prior authorizations.
Member Request to Access or Share Health Information Form

Request the sharing of your health care records and what information may be shared.
Primary Care Provider (PCP) Change Card Choose or change your primary care provider.
Prior Authorization - Referral Form Request a prior authorization for medical services you want IHN-CCO to cover.
Request for Health Plan Records Form Request any health plan documentation from us.
Physician Incentives Brochure Learn how IHN-CCO pays a provider or group of providers.