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Samaritan Advantage HMO Plans - Conventional, Premier, Premier Plus, and Special Needs Plans 

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

Prior Authorization Form  
DME Prior Authorization Form 
Imaging Prior Authorization Form
Member Request to Change PCP Form
Medication Redetermination Form
Prescription Mail Order Transfer Form - to transfer member prescription drugs to Samaritan Health Services Pharmacy for mail order
Waiver of Liability Statement – 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.

 

Samaritan Employer Groups Plans - Standard, Health & Wellbeing, New Performance, Everyday Choices, and Momentum

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

Prior Authorization Form
DME Prior Authorization Form
Imaging Authorization

Samaritan Choice Plans for Employees of Samaritan Health Services

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

Prior Authorization Form
DME Prior Authorization Form
Imaging Prior Authorization Form
Disabled Dependent Determination Form
Prescription Mail Order Transfer Form - to transfer member prescription drugs to Samaritan Health Services Pharmacy for mail order
SamFit/SAM Physical Therapy Reimbursement Request Form

InterCommunity Health Network Coordinated Care Organization (IHN-CCO) for Benton, Lincoln, Linn Counties, Oregon

Talk with our Provider Services representatives 

call us at 541-768-5207">541-768-52071-888-435-2396">1-888-435-23968 a.m. to 5 p.m.
Mon. - Fri.