Office of Private Health Partnerships Publications And Forms

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Office of Private Health Partnerships

Publications And Forms

Order Publications And Forms

To order forms, contact us at our customer service number at 503-373-1693 or 1-800-542-3104, (Toll-Free in Oregon)

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):
Spring 2013 | 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 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)
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 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:

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)
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)

OMIP/FMIP publications
2013 Documents:

OMIP/FMIP 2013 rates (.pdf)
OMIP/FMIP 2013 member handbook (.pdf)
OMIP 2013 plan 500 contract (.pdf)
OMIP 2013 plan 750 & plan 1000 contract (.pdf)
OMIP 2013 plan 1500 contract (.pdf)
FMIP 2013 plan 500 & plan 750 contract (.pdf)
2013 benefit plan summary (.pdf)

OMIP/FMIP publications
2012 Documents:

OMIP producer publications and forms

OMIP/FMIP authorization to disclose protected health information form (.pdf fillable form)
OMIP producer guide (.pdf)
OMIP/FMIP newsletters (.pdf):
Fall Winter 2012 Newsletter.pdf | spring_2012.pdf | Fall 2011 | Winter 2011 | Summer 2010

Enrollment Statistics

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)

PDF File Accessibility

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