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.
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.
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.
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.