Access and download forms and resources for your clients. Don’t hesitate to contact us if you need assistance.
Administrative Quick GuideOregon Standardized Group Profile FormMember Enrollment, Termination, Change & Waiver FormMember Enrollment, Termination, Change & Waiver Form – SpanishMaster Group Application FormRenewal Change Form
You can also download small group plan documents.
Administrative Quick GuideOregon Standardized Group Profile FormMember Enrollment, Termination, Change & Waiver FormMaster Group ApplicationRenewal Change Form
You can also download large group plan documents.
Pre-enrollment ChecklistEnrollment Form Instructions2024 Enrollment Form2023 Enrollment FormScope of Appointment FormNondiscrimination NoticeMulti-Language Interpreter Services
Completed forms may be faxed directly to our Enrollment Department at 541-768-9778 or emailed to SHPOMemberEnrollment@samhealth.org.
It is expected that the agent’s received date(s) for the completed enrollment form and completed scope of appointment form each be documented on the forms in order to be compliant.
The following plan documents are available to help you serve your clients interested in our Samaritan Advantage plans and can be used to complete an enrollment information kit.
2024 Plans Overview2024 Low Income Subsidy Premium Summary2024 Summary of Benefits – Premier & Premier Plus Plans2024 Summary of Benefits – Valor2024 Prior Authorization List
2023 Plans Overview2023 Low Income Subsidy Premium Summary2023 Summary of Benefits – Conventional, Premier & Premier Plus Plan (updated 2/2/2023)2023 Prior Authorization List2023 Over-the-Counter Drug List2023 Star Ratings
Also see detailed information on our Benefits Mastercard and Rewards & Incentives Program.
To find a dental provider, choose any dental provider who has not opted-out of participating in Medicare programs. Review CMS Opt-Out List.
Can’t find what you’re looking for? Search our document library.
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