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
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.