Your Member Forms – Employer Group

The following forms should be sent to Samaritan Health Plans:

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

Appeal Request (English): Use this form if you intend to appeal a benefit coverage decision made by Samaritan Health Plans.

Authorized Representative Form (English) or Authorized Representative (Español): Use this form to grant someone permission to speak with us on your behalf. This form will allow your representative to file an appeal or grievance, as well as request services or communication regarding your care coordination, benefits, claims and other health information.

Coordination of Benefits (English): To properly process your claims, Samaritan Health Plans needs periodic updates regarding your other health insurance coverage.

Disabled Dependent Certification (English): Request continuance of coverage for a dependent that is reaching the limiting age of coverage.

Medication Exception (English): Request a medication exception to Samaritan Health Plans’ coverage rules, e.g., covering your drug even if it is not on the formulary, waiving coverage restrictions or limits on your drug, or providing a higher level of coverage for your drug.

Medical Reimbursement Claim (English): Request reimbursement for services that you have received and paid for that are a covered benefit.

Prescription Reimbursement Claim (English): Request reimbursement for prescriptions obtained at a non-participating pharmacy.

Record Request Form (English): 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.