OHP Forms and publications
Find forms and publications for Oregon Health Plan (OHP) applicants, clients, providers, plans, outreach partners, and DHS/OHA staff.
Go to the DHS/OHA Forms Search Page for other DHS/OHA forms, and to find versions of DHS/OHA 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
Also see the OHP medical and dental plans by county. You need to select a medical and dental plan when you apply for OHP.
| Applying for OHP |
Helpful information
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OHP 7210W - OHP Application - Submit Online
Disponible en español
На русском языке
Hiện có bằng tiếng Việt OHP 9025 - Information about the Oregon Health Plan
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OHP 3256 - It May Be for You
OHP 3259 - Can I be on the OHP and have private health insurance? (En Español)
OHP 7205 -Documents Accepted as Proof of Citizenship
OHP 7300 - Citizenship Requirements Poster; also available in Spanish, Russian and Vietnamese
OHP 7229 - Need help filling out your application? (in English, Spanish, Russian and Vietnamese)
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For clients
About your benefits |
Plan enrollment forms
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Other forms
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DMAP 1418 - Oregon Health Plan - Important Information about your coverage letter and Medical Care ID; En Español
OHP 3259 - Oregon Health Plan - Can I be on the OHP and have private health insurance; En Español
OHP 7224 - Oregon Health Plan - Dental benefits; En Español
OHP 9035 - Oregon Health Plan - Client Handbook; En Español
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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.
OHP 7208M - Medicare Advantage Plan Election; En Español
OHP 7209 - Request to Terminate Insurance
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DMAP 390 - Request to Change Pharmacy - For Pharmacy Management Program clients
DMAP 3083 - Subsidized Adoptions - Reimbursement Request
DMAP 3086 - Subsidized Adoptions - Prior Authorization Request
OHP 3001 - OHP Complaint Form; En Español
OHP 3360 - Pregnancy Notification
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For outreach sites
Outreach forms |
Application help |
Other forms |
DMAP 6670 - Outreach Facility Update
OHA 3128 - Outreach Facility Application
OHA 3274 - Quarterly Report Form
OHA 6625 - Order Form for Applications
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OHP 3259 - Can I be on OHP and have Private Health Insurance?
OHP 7205 - Documents Accepted as Proof of Citizenship
OHP 9025 - Find information about citizenship requirements
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DHS 5530 - Combined Standards Chart (FPL)
DMAP 2410 - Newborn Notification Form
OHP 3261 - Inpatient Hospital Hold Request
OHP 3360 - Pregnancy Notification
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For plans
Member notices |
Provider enrollment
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Other forms
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DMAP 2405
Service Denial Notification
DMAP 3030
Notice of Hearing Rights
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DMAP 3108
Managed Care and FFS Non-Paid Provider Enrollment Form
-Use an EDMS Coversheet for each request
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DMAP 3160
Provider Web Portal Quick Setup Guide
OHA 8708 New!
Insurance Notification Form
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For providers
For information on how to complete provider forms, review OHP Billing Tips or the provider guidelines for your program. Forms marked with an asterisk must be submitted using an EDMS Coversheet for each request. Looking for Electronic Data Interchange (EDI) forms? Go to the EDI Registration and Testing page to download forms and instructions.
Provider enrollment updates
For enrollment forms, see the OHP Provider Enrollment page. |
Authorization
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Billing
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DHS 0189
Direct Deposit Authorization Form
DMAP 3035
Provider Information Update
*DMAP 3108
Managed Care and FFS Non-Paid Provider Enrollment Form
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DHS 3970
EDMS Cover Sheet
*DHS 3971
Oregon DHS Prior Authorization Request - Click here for instructions
*DMAP 3047
Augmentative Communication Device Selection Summary Report
DMAP 3083
Subsidized Adoptions - Reimbursement Request
DMAP 3084
Request for Transplant Evaluation
*DMAP 3155
Positioner Justification - Positioners for Standing
DMAP 3978
Prior Authorization Request for Pharmacy and Oral Nutritional Supplements
*DMAP 1074
Prior Authorization for Out-of-State Services
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DMAP 505
Medicare/Medicaid Billing Invoice (continuous)
DMAP 1036
Individual Adjustment Request
DMAP 1419
MAC Local Match Leveraging Form
DMAP 3049
MMIS Local Match Leveraging Form
DMAP 3085
Request for Administrative Review
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| Documentation |
Miscellaneous |
Provider Web Portal and AVR guides
For more resources, go to the Provider Web Portal page. |
DMAP 590
Private Duty Nursing Psychosocial Grid
DMAP 591
Private Duty Nursing Acuity Grid
DMAP 741
Hysterectomy Consent; also in Spanish
DMAP 742A
Consent to Sterilization; also in Spanish
DMAP 742B
Ages 15-20 Consent to Sterilization; also in Spanish
DMAP 2461
Evaluation of Respiratory Assist Device
DMAP 2470
Maternity Case Management - Initial Assessment
DMAP 2471
Maternity Case Management - Training and Education Tracking
DMAP 2472
Maternity Case Management - Home and Environmental Assessment
DMAP 2473
Maternity Case Management - Five A's Intervention Record (FAIR) for Smoking Cessation
DMAP 9033
Lead Risk Assessment Questionnaire
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AAAC Pharmacy Rate Review Request
DMAP 2410
Newborn Notification
DMAP 3027
FQHC/RHC Cost Statement; also in MS Excel
DMAP 3030
Notice of Hearing Rights
DMAP 3079
Notice of TPO Exemption to HIPAA Privacy Requirements
DMAP 3131
PCPCH Patient Reporting Template
Form 42
Hospital Cost Settlement form and instructions
OHA 8708 New!
Insurance Notification Form
OHP 3360
Pregnancy Notification
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DMAP 3160
Provider Web Portal Quick Setup Guide
DMAP 3161
How to read the Web portal eligibility verification screen
DMAP 3162
Oregon Automated Voice Response - Quick Reference Guide
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For DHS/OHA staff
Refer to the DMAP Worker Guide for staff information on how to complete DMAP forms.
Administrative exams and reports
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Enrollment change requests
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Transportation
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DMAP 729
Administrative Medical Examination and Report Authorization
DMAP 729A
Psychiatric/Psychological Evaluation
DMAP 729C
Eye Exam Report
DMAP 729D
Medical Record Checklist
DMAP 729E
Physical Residual Function Capacity Report
DMAP 729F
Mental Residual Function Report
DMAP 729G
Impairment Severity Rating Report
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DMAP 390 - Request to Change Pharmacy - For Pharmacy Management Program clients
DMAP 473 - Request for PCCM Enrollment Override
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.
OHP 7207 - Continuity of Care Referral
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DMAP 405T
Medical Transportation Order
DMAP 409
Medical Transportation Screening/Input Document
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