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Your Forms

Here are some forms you or your provider may need. These forms relate to your coverage.

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. 

Flexible Services Request Form

Flexible Services Instructions

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.

Flexible Services Request Form 123.6 KB Request health-related services that OHP does not cover.