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 | 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. |
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. |
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. |