| Accident/Injury Report 378.6 KB | Use this form to report information regarding an accident or injury for claim processing. |
| Appeal Request Form 121.61 KB | Ask IHN to change a decision made about your medical coverage. |
| Authorized Representative Form 175.39 KB | You have the right to choose an Authorized Representative. This person has your permission to discuss your health information with IHN. |
| Dental Plan Choice Card 66.02 KB | Choose or change your dental plan. |
| Request health-related services that OHP does not cover. | |
| Hearing Request Form |
Request an administrative hearing from the Department of Medical Assistance Programs (DMAP). |
|
Medication Exception
285.79 KB
|
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
80.33 KB
|
Choose or change your primary care provider. |
|
Prior Authorization - Referral Form
23.95 KB
|
Request a prior authorization for medical services you want IHN to cover. |
| Request for Health Plan Records Form 22.84 KB | Request any health plan documentation from us. |
| Physician Incentives Brochure 139.62 KB | Learn how IHN-CCO pays a provider or group of providers. |
