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Forms and publications
This page contains links to forms and publications produced by the Division of Medical Assistance Programs (DMAP) for Oregon Health Plan (OHP) applicants, clients, providers, plans, outreach partners, and DHS staff. All forms are in Portable Document Format (PDF).
Go to the DHS Forms Search Page for other DHS forms, and to find versions of DHS forms in Spanish and other languages.
If you need a form or publication in a different format, such as (but not limited to) Braille, large print, audio tape, computer disk (in ASCII format) or oral presentation, contact your worker.
For applicants
| Publications |
Forms |
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OHP 3256
It May Be for You
OHP 3259
Can I be on the OHP and have private health insurance? (Also in Spanish)
OHP 7205
Documents Accepted as Proof of Citizenship
OHP 7206
Citizenship Requirements
OHP 7222
Proof required for OHP applicants
OHP 7229
Need help filling out your application? (in English, Spanish, Russian and Vietnamese)
OHP 9025
Information about the Oregon Health Plan
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OHP 7210
OHP Application – Sample only
OHP 7210W 
OHP Application - Submit Online
Disponible en español
На русском языке
Hiện có bằng tiếng Việt
DMAP 6681
Healthy Kids Program information; also in Spanish
OHP 3261
Inpatient Hospital Hold Request – To be completed by the hospital
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For clients
| Publications |
Forms |
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OHP 9035
Oregon Health Plan - Client Handbook; also in Spanish
OHP 3259
Oregon Health Plan - Can I be on the OHP and have private health insurance; also in Spanish
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OHP 3001
OHP Complaint Form; also in Spanish
OHP 7208M
Medicare Advantage Plan Election; also in Spanish
OHP 7209
Request to Terminate Insurance
OHP 3360
Pregnancy Notification
OHP 7207
Continuity of Care Referral
DMAP 390
Request to Change Pharmacy – For Pharmacy Management Program clients
DMAP 720
AI/AN Health Plan Disenrollment Request – For American Indian/Alaska Native clients who do not want to be enrolled in a DMAP medical, dental, or mental health plan.
DMAP 3086
Subsidized Adoptions - Prior Authorization Request
DMAP 3083
Subsidized Adoptions - Reimbursement Request
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For providers, plans and outreach partners
Most forms for providers, plans and outreach partners are on the DMAP Forms page. Links to specific forms series on this page are listed below with a description of provider, plan or outreach forms included in each series.
- For information on how to complete provider forms, review OHP Billing Tips or the provider guidelines for your program.
- For more information about Healthy Kids, go to www.oregonhealthykids.gov.
- Looking for Electronic Data Interchange (EDI) forms? Go to the EDI Registration and Testing page to download forms and instructions.
| DMAP forms |
OHP forms |
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500 Series
Medicare-Medicaid Billing Invoice and private duty nursing forms
700 Series
MediConsent to hysterectomy and Consent to sterilization forms
1000 Series
Individual Adjustment Request, NPI Registration, and Out-of-State prior authorization
1400 Series
OMAC Dispute Resolution and Research Request
2400 Series
Newborn notification, evaluation of respiratory assist device, Maternity Case Management forms
3000 Series
FQHC/RHC cost statement, ACD selection summary report, MMIS local match leveraging, direct deposit authorization, request for transplant evaluation
3100 Series
Provider Enrollment attachments; quick guides for Web portal and Automated Voice Response (AVR); Primary Care Manager (PCM) application; positioner justification
3200 Series
Quarterly reporting form for outreach facilities
3900 Series
Prior authorization for prescriptions and oral nutritional supplements
6000 Series
Outreach facility forms
9000 Series
Lead Risk Assessment Questionnaire
Miscellaneous Forms
Hospital cost settlement form; EDMS coversheet; general PA request form; MAC local match leveraging
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OHP 6680
Healthy Kids Certified Application Assistance Organization Application
OHP 6684
Certified Application Assistance Training Registration
OHP 7205
Documents Accepted as Proof of Citizenship
OHP 7206
Citizenship Requirements
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For DHS staff
These forms are on the DMAP Forms page. Links to specific forms series on this page are listed below with a description of the staff forms included in each series. Refer to the DMAP Worker Guide for staff information on how to complete DMAP forms.
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400 Series
Medical transportation forms and Primary Care Manager override requests
700 Series
Administrative examination and report forms (729 series)
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3000 Series
Notice of Exemption to TPO requirements, Notice of Hearing Rights
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