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Provider Forms

Access Plan Forms

Find the form you need by selecting plan type.

Samaritan Advantage HMO Plans – Conventional, Premier, Premier Plus & Special Needs Plans 

You have the option to submit authorizations online through your provider portal, Provider Connect.

Appeal Request Form (English)
Case Management Referral Form (English)
Dispute Resolution Request Form (English)
Hepatitis C Therapy Prior Authorization Form (English)
Medication Redetermination Form (English)
Member Request to Change PCP Form (English)
Part D Vaccine Reimbursement Form (English)
Prescription Mail Order Transfer Form (English) – to transfer member prescription drugs to Samaritan Health Services Pharmacy for mail order
Prior Authorization Form (English)
Prior Authorization Form Instructions (English)
Rx Exception/Prior Authorization Form (English)
Waiver of Liability Statement (English) – Non-contracted providers must include a signed Waiver of Liability form holding the enrollee harmless in order to request a reconsideration of the plan’s denial of payment. The reconsideration must be filed within 60 calendar days from the remittance notification.

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Provider Prescription Prior Authorization Requests

Select medications may require prior authorization. A physician may submit authorization requests by:

  • Faxing the plan using the form below.
  • Submit electronically using one of our partners below (CoverMyMeds or Surescripts).

You can call Customer Service for additional questions at 541-768-5207 or toll free at 888-435-2396.

Prescription Prior Authorization Form (English)
Submit Authorization to CoverMyMeds
Submit Authorization to Surescripts
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