Your Member Forms – Samaritan Choice

Samaritan Choice Plans Forms 

The following forms should be sent to Samaritan Choice Plans:

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

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

Authorized Representative: 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: To properly process your claims, Samaritan Choice Plans needs periodic updates regarding your other health insurance coverage. More information on double coverage.

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

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.

Medication Exception: Request medication exception to Samaritan Choice 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.

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

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.

Samaritan Human Resources Department Forms

The following form needs to be turned into your local Samaritan Human Resources Department for approval:

Affidavit of Domestic Partnership: Add a person to the health plan as a Domestic Partner if criteria have been met.

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