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. |
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Appeal Request Form Appeal Request Form - Spanish |
Ask IHN-CCO to change a decision made about your medical coverage. |
Authorization for Verbal Communication Form |
Use this form to grant us permission to speak with someone else regarding your benefits, claims or other health information. |
Care Coordination Request Form |
As a new member, you may have questions or concerns about your ongoing care needs. Use this form to enroll in the Care Coordination Program. |
Complaint Grievance Form Complaint Grievance Form (Spanish) |
Use this form to file a complaint or grievance with IHN-CCO. |
Dental Plan Choice Card | Choose or change your dental plan. |
Flexible Services Request Form Flexible Services Request Form (Spanish) |
Request health-related services that OHP does not cover. Review the flexible services instructions (Spanish 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. |
Prescription Reimbursement Form | Submit this form with a receipt to the claims administrator for payment. |
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. |
Physician Incentives Brochure | Learn how IHN-CCO pays a provider or group of providers. |
Record Request Form |
Use this form if you are a member or someone other than the member (or their legal representative) and need to request a copy of the member’s record for which the member’s authorization is required. |