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OHP Forms and Publications

Find forms and publications for Oregon Health Plan (OHP) applicants, clients, providers, plans, outreach partners, and DHS/OHA staff.


Need help?


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.

Providers and plans can order printed forms using the MSC 8100 form.

Members can call OHP Client Services at 1-800-273-0557 to ask for an OHP Handbook. 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.

Category
  
  
  
Description
For ApplicantsOHP 9025English

Your guide to completing the Oregon Health Plan​​​ application

For ApplicantsOHP 3256English

The Oregon Health Plan - It May Be for You​

For ApplicantsOHP 7205English

Documents Accepted as Proof of Citizenship​

For ApplicantsOHP 7229English

Need help filling out your application? (English, Spanish, Russian and Vietnamese)​

For MembersDMAP 1418English

Your Oregon Health Plan benefits

For MembersDMAP 1418Spanish

Your Oregon Health Plan benefits (Spanish)

For Applicants, For MembersOHP 3259English

Can I be on the Oregon Health Plan and have private health insurance?​

For Applicants, For MembersOHP 3259Spanish

Can I be on the Oregon Health Plan and have private health insurance? (Spanish)​

For MembersOHP 7224English

Oregon Health Plan - Dental benefits​

For MembersOHP 7224 - SpanishSpanish

Oregon Health Plan - Dental benefits (Spanish)​

For MembersOHP 9035Spanish

Oregon Health Plan Handbook​

For MembersOHP 9035English

Oregon Health Plan Handbook​

For MembersOHP 7208MEnglish

​Medicare Advantage Plan Election​

For MembersOHP 7208MSpanish

​​Medicare Advantage Plan Election (Spanish)​

For MembersOHP 7209English

Request to End Medicare Advantage and Medicare Special Needs Plan Enrollment

For Members, For DHS/OHA StaffDMAP 390English

Request to Change Pharmacy - For Pharmacy Management Program clients​

For Members, For ProvidersDMAP 3083English

Subsidized Adoptions - Reimbursement Request for Non-Emergent Medical Transportation (for prior-authorized trips only; submit within 30 days of travel)​

For MembersDMAP 3086English

​​​Subsidized Adoptions - Prior Authorization Request for Non-Emergent Medical Transportation​

For MembersOHP 3001English

OHP Complaint Form​

For MembersOHP 3001Spanish

OHP Complaint Form (Spanish)​

For Outreach Sites, For Providers, For DHS/OHA StaffOHA 6625English

Order Form for OHP Applications and Plan Comparison Charts​

For Members, For Outreach Sites, For ProvidersDMAP 2410English

Newborn Notification Form​

For Members, For Health PlansDMAP 3030English

Notice of Hearing Rights​

For Health PlansDMAP 3108English
Managed Care Provider Enrollment Form - Use an EDMS Coversheet for each request
For DHS/OHA StaffDMAP 729English

Administrative Medical Examination and Report Authorization​

For DHS/OHA StaffDMAP 729AEnglish

Psychiatric/Psychological Evaluation​​

For DHS/OHA StaffDMAP 729CEnglish

Eye Exam Report​

For DHS/OHA StaffDMAP 729DEnglish

Medical Record Checklist​

For DHS/OHA StaffDMAP 729EEnglish

Physical Residual Function Capacity Report​

For DHS/OHA StaffDMAP 729FEnglish

Mental Residual Function Report​

For DHS/OHA StaffDMAP 729GEnglish

Impairment Severity Rating Report​

For ProvidersDMAP 405TEnglish

Medical Transportation Order (for Transportation Brokerages)​

For DHS/OHA StaffDMAP 409English

Medical Transportation Screening/Input Document​

For Members, For DHS/OHA StaffDMAP 720English
AI/AN Enrollment Status Change Request - For American Indian/Alaska Native clients can use this form to change their current fee-for-service ("open card") or OHP health plan enrollment.
For DHS/OHA StaffOHP 7207English

Continuity of Care Referral​

For ProvidersDMAP 1074English

Prior Authorization for Out-of-State Services​

For ProvidersDMAP 3978English
Prior Authorization Request for Pharmacy and Oral Nutritional Supplements
For ProvidersDMAP 3155English

Positioner Justification - Positioners for Standing​​

For ProvidersDMAP 9033English

Lead Risk Assessment Questionnaire​

For ProvidersDMAP 2473English

Maternity Case Management - Five A's Intervention Record (FAIR) for Smoking Cessation​

For ProvidersDMAP 2472English

Maternity Case Management - Home and Environmental Assessment​

For ProvidersDMAP 3084 - PDFEnglish

Request for Transplant or Transplant Evaluation

For ProvidersDHS 0189English

Direct Deposit Authorization Form​

For ProvidersDMAP 3035English

Provider Information Update​

For ProvidersDMAP 3113English

Submit if you only need to enroll with DMAP for non-billing purposes (e.g., as a rendering, ordering, prescribing, referring provider; or for Provider Web Portal access).​

For ProvidersDMAP 3162English

Oregon Medicaid Automated Voice Response - Quick Reference Guide​

For ProvidersDMAP 3161English

How to read the Provider Web Portal eligibility verification screen​

For Health Plans, For ProvidersDMAP 3160English

Provider Web Portal Quick Setup Guide​

For ProvidersDHS 3970English

EDMS Cover Sheet​

For ProvidersDMAP 505English

Medicare/Medicaid Billing Invoice​

For ProvidersDMAP 1036English

Individual Adjustment Request​

For ProvidersDMAP 1419English

MAC Local Match Leveraging Form - Unit of government providers use this form to submit local match prepayments for Medicaid Administrative Claiming (MAC) activities billed to DHS/OHA.​

For ProvidersDMAP 3049English

MMIS Local Match Leveraging Form​ - Unit of government providers use this form to submit local match prepayments for claims submitted by their service providers. This form is also available in Word​.

For ProvidersOHP 3085English

Request for Claim or Service Authorization Review (formerly Request for Administrative Review)

For ProvidersDMAP 3047English

Augmentative Communication Device Selection Summary Report​

For ProvidersMSC 3971English
DHS/OHA Prior Authorization Request - instructions
For ProvidersDMAP 2471English

Maternity Case Management - Training and Education Tracking​

For ProvidersDMAP 2470English

Maternity Case Management - Initial Assessment​

For Members, For Outreach Sites, For ProvidersOHP 3360English

Pregnancy Notification​

For Members, For Health Plans, For Outreach Sites, For Providers, For DHS/OHA StaffMSC 415HEnglish

Insurance Notification Form​

For ProvidersDMAP 2461English

Evaluation of Respiratory Assist Device​

For ProvidersDMAP 742BEnglish
Ages 15-20 Consent to Sterilization
For ProvidersDMAP 742BSpanish
Ages 15-20 Consent to Sterilization - Spanish
For ProvidersDMAP 590English

Private Duty Nursing Psychosocial Grid​

For ProvidersDMAP 591English

Private Duty Nursing Acuity Grid​

For ProvidersDMAP 741English

Hysterectomy Consent​

For ProvidersDMAP 741Spanish

Hysterectomy Consent - Spanish​

For ProvidersDMAP 742AEnglish

Consent to Sterilization​

For ProvidersDMAP 742ASpanish

Consent to Sterilization - Spanish​

For ProvidersDMAP 3131English

Per Member Per Month (PMPM) Patient Reporting Template​ - For Alternate Payment Methodology (APM) and Patient-Centered Primary Care Home (PCPCH) payments

For ProvidersDMAP 3079English

Notice of TPO Exemption to HIPAA Privacy Requirements​

For ProvidersDMAP 3027English

FQHC/RHC Cost Statement​

For MembersOHP 9035English

Oregon Health Plan Handbook (Large Print)​

For MembersOHP 9035Russian

Oregon Health Plan Handbook​

For MembersOHP 9035Vietnamese

Oregon Health Plan Handbook​

For MembersDMAP 1418Russian

Your Oregon Health Plan benefits (Russian)

For MembersDMAP 1418Vietnamese

Your Oregon Health Plan benefits (Vietnamese)

For MembersOHP 7208MVietnamese

Medicare Advantage Plan Election (Vietnamese)​

For MembersOHP 7208MRussian

Medicare Advantage Plan Election (Russian)​

For ProvidersDMAP 525English

Hospice in a Nursing Facility Notification Form​

For MembersMail Order Prescription FormEnglish

Mail Order Prescription Form (English) - This service is for ongoing monthly prescriptions for services covered by DMAP on a fee-for-service (“open card”) basis.​

For MembersMail Order Prescription FormSpanish

Mail Order Prescription Form (Spanish) - This service is for ongoing monthly prescriptions for services covered by DMAP on a fee-for-service (“open card”) basis.​

For MembersA&D Resource DirectoryEnglish

Oregon Alcohol & Other Drug Services Directory

For MembersDMAP 527English

When an Oregon Medicaid client in a nursing facility elects hospice care​

For Members, For Health PlansDMAP 3030Spanish

Notice of Hearing Rights​

For Members, For Health PlansDMAP 3030Russian

Notice of Hearing Rights​

For Members, For Health PlansDMAP 3030Vietnamese

Notice of Hearing Rights​

For ProvidersDMAP Provider Enrollment FormsEnglish

Find all forms you need to complete for your provider type​

For ProvidersDMAP 3130English

Primary Care Manager Application - See OAR 410-141-0860 for PCM enrollment requirements​

For ProvidersDMAP 3163English

How to use the Provider Web Portal Benefits and Prioritized List Inquiry screen​

For ProvidersDMAP 2120English

OHA Provider Discrimination Review Request​

For ProvidersDMAP 3046English

Fee-for-Service Provider Contacts List - Includes common telephone numbers, email addresses, websites, fax numbers, and mailing addresses​

For MembersDMAP 3082English

Oregon Health Plan Overview for Certified Families ​

For ProvidersDMAP 3074English

Oregon Health Plan electronic business practices - Learn how to do paperless business with DMAP using the Provider Web Portal, electronic data interchange and direct deposit​

For ProvidersOHA 8705English

Law Enforcement Medical Liability Account (LEMLA) Claim - Enrolled Oregon Medicaid providers can complete this form with one year of date of injury and submit it to the law enforcement agency believed responsible for a patient's "injuries related to law enforcement activity." See LEMLA rules for more information​

For MembersOHP 3001Russian

OHP Complaint Form (Russian)​

For MembersOHP 3001Vietnamese

OHP Complaint Form (Vietnamese)​

For ApplicantsOHP 3256Russian

The Oregon Health Plan - It May Be For You (Russian)​

For ApplicantsOHP 3256Spanish

The Oregon Health Plan - It May Be For You (Spanish)​

For ApplicantsOHP 3256Vietnamese

The Oregon Health Plan - It May Be For You (Vietnamese)​

For Applicants, For MembersOHP 3259Russian

Can I be on the Oregon Health Plan and have private health insurance? (Russian)​

For Applicants, For MembersOHP 3259Vietnamese

Can I be on the Oregon Health Plan and have private health insurance? (Vietnamese)​

For ApplicantsOHP 9025Spanish

Your guide to completing the Oregon Health Plan application (Spanish)​

For ApplicantsOHP 9025Russian

Your guide to completing the Oregon Health Plan application (Russian)​

For ApplicantsOHP 9025Vietnamese

Your guide to completing the Oregon Health Plan application (Vietnamese)​

For ApplicantsOHP 9025English

Your guide to completing the Oregon Health Plan application (Large Print)​

For MembersMSC 443English

DHS/OHA Administrative Hearing Request Form​

For MembersMSC 443Spanish

DHS/OHA Administrative Hearing Request Form​

For MembersMSC 443Russian

DHS/OHA Administrative Hearing Request Form (Russian)​

For MembersMSC 443Vietnamese

DHS/OHA Administrative Hearing Request Form (Vietnamese)​

For ProvidersDMAP 7204English

​Substance Use Disorder Residential Treatment Facility Admission/Discharge Notification

For ProvidersDMAP 3165English

​OHP Client Agreement to Pay for Health Services​

For ProvidersOHP 7260English

​Application for Hospital Presumptive Eligibility - English (Word)

For ProvidersOHP 3263AEnglish

​Approval Notice for Hospital Presumptive Eligibility - English (PDF)

For ProvidersOHP 3263BEnglish

​Denial Notice for Hospital Presumptive Eligibility - English (PDF)

For ProvidersOHP 7260English

Application for Hospital Presumptive Eligibility​ - English (Word)

For ProvidersOHP 3263AEnglish

​Approval Notice for Hospital Presumptive Eligibility - English (Word)

For ProvidersOHP 3263BEnglish

​Denial Notice for Hospital Presumptive Eligibility - English (Word)

For Health PlansDMAP 3302English

Service Denial and Hearing Request Form​

For Health PlansDMAP 3302English

Service Denial Appeal and Hearing Request (English large print)​

For Health PlansDMAP 3302Spanish

Service Denial Appeal and Hearing Request (Spanish)​

For Health PlansDMAP 3302Vietnamese

Service Denial Appeal and Hearing Request (Vietnamese)​

For Health PlansDMAP 3302Russian

Service Denial Appeal and Hearing Request (Russian)​

For Health PlansDMAP 2405English

Notice of Action - English template for OHP health plans​

For Health PlansDMAP 2405Spanish

Notice of Action - Spanish template for OHP health plans​

For Health PlansDMAP 2405Vietnamese

Notice of Action - Vietnamese template ​for OHP health plans

For Health PlansDMAP 2405Russian

Notice of Action - Russian template for OHP health plans​

For MembersOHP 9040 - EnglishEnglish

Oregon Health Plan client toolkit - Learn about getting OHP services and when you may need to pay for services​

For MembersOHP 9040A - EnglishEnglish

Oregon Health Plan Client Tip Sheet 1 – Getting started

For MembersOHP 9040B - EnglishEnglish

Oregon Health Plan Client Tip Sheet 2 – Prior authorization​

For MembersOHP 9040C - EnglishEnglish

Oregon Health Plan Client Tip Sheet 3 – Notice of Action​

For MembersOHP 9040D - EnglishEnglish

Oregon Health Plan Client Tip Sheet 4 – Appeals and hearings​

For MembersOHP 9040E - EnglishEnglish

Oregon Health Plan Client Tip Sheet 5 – Co-payments​

For MembersOHP 9040F - EnglishEnglish

Oregon Health Plan Client Tip Sheet 6 – Paying for covered services​

For MembersOHP 9040G - EnglishEnglish

Oregon Health Plan Client Tip Sheet 7 – Paying for non-covered services​

For MembersOHP 9040H - EnglishEnglish

Oregon Health Plan Client Tip Sheet 8 – What to do if you get a bill​

For MembersOHP 9040I - EnglishEnglish

Oregon Health Plan Client Tip Sheet 9 – Your rights and responsibilities​

For MembersOHP 9040JEnglish

Oregon Health Plan Client Tip Sheet 10 (English) – Forms and resources​

For ProvidersOHP 3262English

Declaration of Intent and Agreement to Serve as a Hospital Presumptive Eligibility Site - For enrolled Oregon Medicaid hospitals​

For ProvidersOHP 3262English

Declaration of Intent and Agreement to Serve as a Hospital Presumptive Eligibility Site - For enrolled Oregon Medicaid hospitals​

For ProvidersDMAP 3165Spanish
OHP Client Agreement to Pay for Health Services (Spanish)​​
For ProvidersDMAP 2405TEnglish

Notice of Action (English) - Template for contracted transportation brokerages​

For ProvidersDMAP 2405TSpanish

Notice of Action (Spanish) - Template for contracted transportation brokerages​

For ProvidersDMAP 3165Russian

OHP Client Agreement to Pay for Health Services​ (Russian)​

For ProvidersDMAP 3165Vietnamese

OHP Client Agreement to Pay for Health Services​ (Vietnamese)​

For ProvidersDMAP 3084 - WordEnglish

Request for Transplant or Transplant Evaluation​

For MembersDMAP 1415English

Coverage Letter insert - How to find out if you are in a CCO or receive services as an "open card" member​

For MembersDMAP 1415 (Large Print)English

Coverage Letter insert (English large print) - How to find out if you are in a CCO or receive services as an "open card" member​

For MembersDMAP 1415Cambodian

Coverage Letter insert (Cambodian) - How to find out if you are in a CCO or receive services as an "open card" member​

For MembersDMAP 1415Korean

Coverage Letter insert (Korean) - How to find out if you are in a CCO or receive services as an "open card" member​

For MembersDMAP 1415Laotian

Coverage Letter insert (Laotian) - How to find out if you are in a CCO or receive services as an "open card" member​

For MembersDMAP 1415Romanian

Coverage Letter insert (Romanian) - How to find out if you are in a CCO or receive services as an "open card" member​

For MembersDMAP 1415Russian

Coverage Letter insert (Russian) - How to find out if you are in a CCO or receive services as an "open card" member​

For MembersDMAP 1415Chinese

Coverage Letter insert (Chinese) - How to find out if you are in a CCO or receive services as an "open card" member​

For MembersDMAP 1415Somali

Coverage Letter insert (Somali) - How to find out if you are in a CCO or receive services as an "open card" member​

For MembersDMAP 1415Vietnamese

Coverage Letter insert (Vietnamese) - How to find out if you are in a CCO or receive services as an "open card" member​

For MembersDMAP 1415Spanish

Coverage Letter insert (Spanish) - How to find out if you are in a CCO or receive services as an "open card" member​

For MembersDMAP 1416English

Sample OHP Coverage Letter and inserts - View the information you will receive when you are new to OHP, have changes to your OHP coverage​, or request a new ID card.

For ProvidersOHA 8061English

Mental Health Discharge Information Form - To be completed whenever an individual moves out of an adult foster care or residential treatment program.​

For ProvidersOHA 8060English

Behavioral Health Prior Authorization Request Form for Outpatient Rehabilitation or Community Habilitation Services​

For ApplicantsApplication WorksheetEnglish

Use this form to gather information needed to apply for medical assistance.

For Applicants, For Outreach SitesOHA 7210English

Oregon Health Plan Application ​

For ProvidersDMAP 531English

Medicaid Personal Care Service Plan Authorization for Mental Health Services​

For ProvidersOHA 8069English

Plan of Care Request for Behavioral Health Residential or Personal Care Services​

For ProvidersOHA 8099English

Level of Service Inventory for Behavioral Health Adult Foster Care Services​

For Providers1915(i) Eligibility FormEnglish

1915(i) Eligibility Determination Request - Fax to Acumentra Health with all required documentation listed at the end of the form.​

For Providers1915(i) Needs-Based CriteriaEnglish

1915(i) Needs-Based Criteria Worksheet - This is an optional document to include with your 1915(i) eligibility determination request to Acumentra Health.​

For ProvidersOHA 3981English

Service Support Assessment for Applied Behavioral Analysis Services

For ProvidersOHA 3980English

Level of Service Inventory for Behavioral Health Residential Treatment Services​

For ProvidersOHP 3263ASpanish

​Approval Notice for Hospital Presumptive Eligibility - Spanish (PDF)

For ProvidersOHP 3263ASpanish

​Approval Notice for Hospital Presumptive Eligibility - Spanish (PDF)

For ProvidersOHP 3263AVietnamese

​Approval Notice for Hospital Presumptive Eligibility - Vietnamese (PDF)

For ProvidersOHP 3263AVietnamese

​Approval Notice for Hospital Presumptive Eligibility - Vietnamese (Word)

For ProvidersOHP 3263ARussian

​Approval Notice for Hospital Presumptive Eligibility - Russian (PDF)

For ProvidersOHP 3263ARussian

​Approval Notice for Hospital Presumptive Eligibility - Russian (Word)

For ProvidersOHP 3263BSpanish

​Denial Notice for Hospital Presumptive Eligibility - Spanish (PDF)

For ProvidersOHP 3263BSpanish

​Denial Notice for Hospital Presumptive Eligibility - Spanish (Word)

For ProvidersOHP 3263BVietnamese

Denial Notice for Hospital Presumptive Eligibility - Vietnamese (PDF)​

For ProvidersOHP 3263BVietnamese

​Denial Notice for Hospital Presumptive Eligibility - Vietnamese (Word)

For ProvidersOHP 3263BRussian

​Denial Notice for Hospital Presumptive Eligibility - Russian (PDF)

For ProvidersOHP 3263BRussian

​Denial Notice for Hospital Presumptive Eligibility - Russian (Word)

For ProvidersOHP 7260Spanish

​Application for Hospital Presumptive Eligibility - Spanish (PDF)

For ProvidersOHP 7260Spanish

​Application for Hospital Presumptive Eligibility - Spanish (Word)

For ProvidersOHP 7260Russian

​Application for Hospital Presumptive Eligibility - Russian (PDF)

For ProvidersOHP 7260Russian

​Application for Hospital Presumptive Eligibility - Russian (Word)

For ProvidersOHP 7260Vietnamese

​Application for Hospital Presumptive Eligibility - Vietnamese (PDF)

For ProvidersOHP 7260Vietnamese

​Application for Hospital Presumptive Eligibility - Vietnamese (Word)

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