Your Member Forms – Medicare Advantage

Accident/Injury Report: Use this form to report information regarding an accident or injury for claim processing.

Appeal Request Form: This form can be used to request an appeal of a medical care coverage decision made by our plan.

Benefits Mastercard Reimbursement Claim Form

Medical Reimbursement Claim: Request reimbursement for services that you have received and paid for that are a covered benefit. Flexible Spending Account (FSA) payments will not be reimbursed by SHP.

Prior Authorization Request Form: This form can be used by your provider to request a service or item that needs prior authorization by our plan.

Request Recurring Electronic Funds Transfer (EFT) Service or One Time Electronic Funds Transfer (EFT) Service: You have the option of paying your monthly premium through automatic withdrawal from your credit / debit card OR personal bank account.

Use this form to disenroll from a Samaritan Advantage Plan.

Samaritan Advantage Disenrollment Form

Medication Exception/Prior Authorization Form: If you are a provider, you can use this form to ask us to make a coverage determination for a prior authorized medication or a medication exception to our coverage rules if the member is on one of our plans that offer prescription drug coverage.

Redetermination Request Form: If we deny your request for coverage of (or payment for) a prescription drugs, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination. This form may be sent to us by mail or fax:

• Address: Samaritan Advantage Health Plans HMO , P.O. Box 1310, Corvallis, OR 97339
• Fax Number: 541-768-9765
• Expedited redeterminations (appeals) requests can by made by phone at 541-768-4550 or toll free at 800-832-4580.

Prescription Mail Order: Use this form when you have a written prescription that you are mailing to Samaritan Health Services.
Samaritan Pharmacy Services FAX Order Form: Provide this form to your physician to fax your prescription to Samaritan Health Services.
Samaritan Pharmacy Services Prescription Transfer Request: Use this form to conveniently transfer all your prescriptions to Samaritan Health Services. We will contact the pharmacies you list on the form for you and have the prescriptions transferred.
Prescription Reimbursement Form: We will cover your prescription at an out-of-network pharmacy under certain conditions.

To designate a representative for appeals and coverage determinations: CMS Form-1696, Appointment of Representative.

You must send a copy to Samaritan Advantage Health Plans HMO each time you want the appointed representative to head any of your appeal requests within 60 days of the initial denial for the service requested. Once the form is received by Samaritan Advantage Health Plans HMO, it is considered current for one year. After one year has passed, you must complete a new form if you would like to continue the appointment of that representative.

We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 800-832-4580. Someone who speaks your language can help you. This is a free service.

Authorized Representative Form: Use this form to grant someone permission to speak with us on your behalf, and to allow your representative to request services or communications regarding your care coordination, benefits, claims and other health information.

Record Request Form: Use this form if you are someone other than the member (or their legal representative) and need to request a copy of our member’s record for which the member’s authorization is required.