Office of Private Health Partnerships Publications And Forms

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Office of Private Health Partnerships

Publications And Forms

Order Publications And Forms

Family Health Insurance Assistance Program (FHIAP)

Healthy KidsConnect (HKC)

Oregon Medical Insurance Pool/Federal Medical Insurance Pool

General Resources

COBRA Publications

Enrollment Statistics


Order Publications And Forms

OPHP's publications and outreach material order form


Family Health Insurance Assistance Program (FHIAP)

FHIAP forms FHIAP add dependent form (Word fillable .doc) FHIAP applicant consent form (.pdf fillable form) FHIAP citizenship requirement (.pdf) FHIAP citizenship requirement (Spanish version) (.pdf) FHIAP direct deposit and change of address information FHIAP other forms packet (.pdf fillable form) - This packet includes the individual forms listed below in one .pdf fillable file. You can download this packet or click on the individual forms: Applicant consent form (.pdf fillable form) No income form (.pdf fillable form) Group insurance information form (.pdf fillable form) Self-employment income worksheet (.pdf fillable form) Corporation/partnership income worksheet (.pdf fillable form) Farming, ranching, and fishing income worksheet (.pdf fillable form) Sample self-employment income worksheet and instructions (.pdf) Extra page for additional family members for FHIAP application (.pdf fillable form) FHIAP request to end FHIAP subsidy (Word fillable .doc) FHIAP request to end OHP medical benefits (Word fillable .doc) FHIAP sample application and instructions (.pdf) FHIAP publications 2012 income guidelines For FHIAP and Healthy Kids (.pdf) FHIAP billing calendar: 2011 \| 2012 (.pdf) FHIAP brochure (.pdf): English \| Spanish \| Vietnamese \| Russian FHIAP kids brochure (.pdf) FHIAP Member Connections newsletter (.pdf): Summer 2008 \| Spring 2008 \| Winter 2008 \| Fall 2007 \| Summer 2007 \| Spring 2007 \| Winter 2007 \| Fall 2006 FHIAP member guide (.pdf) FHIAP privacy notice (.pdf) FHIAP program summary (.pdf) FHIAP roadmap to individual insurance (.pdf) FHIAP subsidy income guideline chart (.pdf) FHIAP and Healthy Kids comparison chart (.pdf) FHIAP employer publications and forms FHIAP employer brochure (.pdf) FHIAP employer guide (.pdf) FHIAP enrollment verification form (.pdf fillable form) How to bring on a new group health plan using the Family Health Insurance Assistance Program (FHIAP) or Healthy Kids (.pdf) Premium savings with FHIAP (Word fillable with calculations .doc) FHIAP producer publications and forms FHIAP approved individual market insurance companies and plans FHIAP benchmark for group health insurance (.pdf) FHIAP producer referral program application (.pdf) FHIAP producer Webinar - Spring 2010 (.pdf) Producer Connections newsletter (.pdf): Winter 2012 \| Spring 2011 \| Fall 2010 \| Summer 2010 \| Spring 2010 \| Summer 2008 \| Spring 2008 \| Winter 2008 \| Fall 2007 \| Spring 2007 \| Winter 2007 FHIAP request for benchmark analysis form (.pdf fillable form) FHIAP roadmap to individual insurance (.pdf) How to bring on a new group health plan using the Family Health Insurance Assistance Program (FHIAP) or Healthy Kids (.pdf) Premium savings with FHIAP (Word fillable with calculations .doc)


Healthy KidsConnect (HKC)

HKC forms HKC consent form (.pdf fillable form) HKC group insurance information form (Word fillable .doc) HKC publications Benefit summaries and handbooks (.pdf): Kaiser: Medical (includes Evidence of Coverage): Low cost option or full cost option Dental (includes Evidence of Coverage): Low cost option or full cost option Medical in Spanish (Includes dental/vision and Evidence of Coverage): Low cost option or full cost option American Indian/Alaskan Native (includes Evidence of Coverage): Medical \| Dental: Low cost option or full cost option PacificSource: Medical/Dental: Low cost option or full cost option Medical/Dental in Spanish: Low cost option or full cost option Handbooks: Low cost option or full cost option Samaritan: Medical/Dental: Low cost option or full cost option \| Handbook Medical/Dental in Spanish: Low cost option or full cost option Trillium: Medical: Low cost option or full cost option Medical in Spanish: Low cost option or full cost option Handbooks: Low cost option or full cost option Handbooks in Spanish: Low cost option or full cost option Other publications: Healthy Kids comparison chart 2012 income guidelines For FHIAP and Healthy Kids (.pdf) FHIAP and Healthy Kids comparison chart (.pdf) Healthy Kids comparison chart (.pdf) How to bring on a new group health plan using the Family Health Insurance Assistance Program (FHIAP) or Healthy Kids (.pdf) HKC producer publications and forms HKC employer sponsored insurance enrollment verification form (Word fillable .doc) HKC federal guidelines for employer-sponsored insurance (.pdf) HKC producer request for federal guideline analysis (.pdf fillable form) How to bring on a new group health plan using the Family Health Insurance Assistance Program (FHIAP) or Healthy Kids (.pdf)


Oregon Medical Insurance Pool/Federal Medical Insurance Pool

OMIP/FMIP forms OMIP/FMIP application Pages 23-32 in the OMIP/FMIP Member Handbook (.pdf fillable form) OMIP/FMIP authorization to disclose protected health information form (.pdf fillable form) OMIP/FMIP automatic payment deduction request form (.pdf fillable form) OMIP/FMIP plan change request form (.pdf) OMIP/FMIP prescription claim form (.pdf) OMIP/FMIP status change form (.pdf) Use this form to add or drop a dependent, change your address, or request a new identification card. OMIP/FMIP Weight Watchers authorization for disclosure and payment (Word fillable .doc) OMIP dependent application (.pdf fillable form) OMIP/FMIP publications 2012 Documents: Rates for FMIP 2012 (.pdf) OMIP/FMIP 2012 Weight Watchers Flier (.pdf) OMIP/FMIP brochure (.pdf): English/Spanish \| English/Russian \| English/Vietnamese OMIP/FMIP free & clear quit for life program flyer (.pdf) OMIP/FMIP health benefit plan summary (.pdf) OMIP/FMIP living well with chronic conditions flyer (.pdf) OMIP/FMIP 2012 member handbook (.pdf) OMIP/FMIP 2012 premium rates and instructions (.pdf) FMIP Contract 500 750 (.pdf) OMIP Contract 500 (.pdf) OMIP Contract 750 1000 (pdf.) OMIP Contract 1500 (.pdf) OMIP/FMIP newsletters (.pdf): Fall 2011 \| Winter 2011 \| Summer 2010 \| Spring 2010 \| Fall 2009 \| Winter 2009 \| Summer 2008 Spring 2008 \| Fall 2007 \| Spring 2007 \| Fall 2006 \| Spring 2006 OMIP producer publications and forms OMIP/FMIP authorization to disclose protected health information form (.pdf fillable form) OMIP producer guide (.pdf)


General Resources

OPHP multimedia resources – online training tools: Train at your convenience. Click here to go to the online library of recent web trainings and audio casts. OPHP's performance measures (.pdf) OPHP's Producer Connections newsletter (.pdf): Winter 2012 \| Spring 2011 \| Fall 2010 \| Summer 2010 \| Spring 2010 \| Summer 2008 \| Spring 2008 \| Winter 2008 \| Fall 2007 \| Spring 2007 \| Winter 2007 State health insurance resources (.pdf)


COBRA Publications

Need help with COBRA payments flyer (All flyers have same text but different graphics): Option 1 \| Option 2 \| Option 3 (.pdf)


Enrollment Statistics

OPHP enrollment statistics summary including Healthy KidsConnect, FHIAP, OMIP, and FMIP (.pdf) Program enrollment statistics: FHIAP \| Healthy KidsConnect \| OMIP \| FMIP Program enrollment statistics: Childrens Reinsurance Program

Page updated: April 30, 2012