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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, to order printed 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.

  • Members and applicants - Use the OHP Comparison Charts to select a health and dental plan when you apply or re-apply for OHP. Learn more on our OHP health and dental plans by county page.
  • Providers - Review OHP Billing Tips or the provider guidelines for your program for more information about provider forms.
  • Providers and plans - Sign up for Electronic Data Interchange (EDI) using the EDI forms. Learn more on our EDI page.
  • Staff - Refer to the DMAP Worker Guide for information on how to complete DMAP forms.
  
  
  
Description
EnglishElectronic Data InterchangeDMAP 2080 (Packet Pages 1-5)

All Trading Partners must sign a TPA in order to do business electronically with Oregon Medicaid. If your trading partner name, Tax ID and/or Oregon Medicaid provider number changes, you will need to submit a new TPA.

EnglishElectronic Data InterchangeDMAP 2081 (Packet Pages 6-8)

Exhibit A of the TPA gives Oregon Medicaid information on who will be submitting your electronic transactions.​

EnglishElectronic Data InterchangeDMAP 2082 (Packet Pages 9-10)

Exhibit B of the TPA tells Oregon Medicaid which electronic transactions that you or your electronic submitters want to register for. ​

EnglishElectronic Data InterchangeDMAP 2083

Use Exhibit C to update contact information listed on Exhibit A and add or delete your registered transaction on Exhibit B. ​

EnglishElectronic Data InterchangeDMAP 2080PKT

To register as an Oregon Medicaid trading partner, complete all three forms in this packet (DMAP 2080, 2081 and 2082).​

EnglishFor ApplicantsOHP 7210W

​​​OHP Application - Submit Online
Disponible en español
На русском языке
Hiện có bằng tiếng Việt

EnglishFor ApplicantsOHP 9025

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

EnglishFor ApplicantsOHP 3256

The Oregon Health Plan - It May Be for You​

EnglishFor ApplicantsOHP 3259

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

SpanishFor ApplicantsOHP 3259

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

EnglishFor ApplicantsOHP 7205

Documents Accepted as Proof of Citizenship​

EnglishFor ApplicantsOHP 7229

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

RussianFor ApplicantsOHP 3256

The Oregon Health Plan - It May Be For You​

SpanishFor ApplicantsOHP 3256

The Oregon Health Plan - It May Be For You​

VietnameseFor ApplicantsOHP 3256

The Oregon Health Plan - It May Be For You​

RussianFor ApplicantsOHP 3259

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

VietnameseFor ApplicantsOHP 3259

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

SpanishFor ApplicantsOHP 9025

Your guide to completing the Oregon Health Plan application​

RussianFor ApplicantsOHP 9025

Your guide to completing the Oregon Health Plan application​

VietnameseFor ApplicantsOHP 9025

Your guide to completing the Oregon Health Plan application​

EnglishFor ApplicantsOHP 9025

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

EnglishFor ApplicantsApplication Worksheet

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

EnglishFor DHS/OHA StaffDMAP 729

Administrative Medical Examination and Report Authorization​

EnglishFor DHS/OHA StaffDMAP 729A

Psychiatric/Psychological Evaluation​​

EnglishFor DHS/OHA StaffDMAP 729C

Eye Exam Report​

EnglishFor DHS/OHA StaffDMAP 729D

Medical Record Checklist​

EnglishFor DHS/OHA StaffDMAP 729E

Physical Residual Function Capacity Report​

EnglishFor DHS/OHA StaffDMAP 729F

Mental Residual Function Report​

EnglishFor DHS/OHA StaffDMAP 729G

Impairment Severity Rating Report​

EnglishFor DHS/OHA StaffMSC415H

Insurance Notification Form​

EnglishFor DHS/OHA StaffDMAP 409

Medical Transportation Screening/Input Document​

EnglishFor DHS/OHA StaffDMAP 390

Request to Change Pharmacy - For Pharmacy management Program Clients​

EnglishFor DHS/OHA StaffDMAP 473

Request for PCCM Enrollment Override​

EnglishFor DHS/OHA StaffDMAP 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.
EnglishFor DHS/OHA StaffOHP 7207

Continuity of Care Referral​

EnglishFor DHS/OHA StaffDMAP 405T

Medical Transportation Order (for DHS branch staff - Washington, Multnomah, and Clackamas counties only)​

EnglishFor Health PlansDMAP 3030

Notice of Hearing Rights​

EnglishFor Health PlansDMAP 3108
Managed Care Provider Enrollment Form - Use an EDMS Coversheet for each request
EnglishFor Health PlansDMAP 3160

Provider Web Portal Quick Setup Guide​

EnglishFor Health PlansMSC415H

Insurance Notification Form​

SpanishFor Health PlansDMAP 3030

Notice of Hearing Rights​

RussianFor Health PlansDMAP 3030

Notice of Hearing Rights​

VietnameseFor Health PlansDMAP 3030

Notice of Hearing Rights​

EnglishFor Health PlansDMAP 3302 (PDF)

Service Denial and Hearing Request ​

EnglishFor Health PlansDMAP 3302 - Large Print (PDF)

Service Denial and Hearing Request​

SpanishFor Health PlansDMAP 3302 (PDF)

Service Denial Appeal and Hearing Request​

VietnameseFor Health PlansDMAP 3302 (PDF)

Service Denial Appeal and Hearing Request​

RussianFor Health PlansDMAP 3302 (PDF)

Service Denial Appeal and Hearing Request​

EnglishFor Health PlansDMAP 3302 (Word)

Service Denial and Hearing Request Form​

EnglishFor Health PlansDMAP 3302 - Large Print (Word)

Service Denial Appeal and Hearing Request​

SpanishFor Health PlansDMAP 3302 (Word)

Service Denial Appeal and Hearing Request​

VietnameseFor Health PlansDMAP 3302 (Word)

Service Denial Appeal and Hearing Request​

RussianFor Health PlansDMAP 3302 (Word)

Service Denial Appeal and Hearing Request​

EnglishFor Health PlansDMAP 2405 - English

Notice of Action - English template for OHP health plans (Word)​

SpanishFor Health PlansDMAP 2405 - Spanish

Notice of Action - Spanish template for OHP health plans (Word)​

VietnameseFor Health PlansDMAP 2405 - Vietnamese

Notice of Action - Vietnamese template ​for OHP health plans (Word)

RussianFor Health PlansDMAP 2405 - Russian

Notice of Action - Russian template for OHP health plans (Word)​

EnglishFor MembersDMAP 1418

Your Oregon Health Plan benefits

SpanishFor MembersDMAP 1418

Your Oregon Health Plan benefits

EnglishFor MembersOHP 3259

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

SpanishFor MembersOHP 3259

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

EnglishFor MembersOHP 7224

Oregon Health Plan - Dental benefits​

SpanishFor MembersOHP 7224 - Spanish

Oregon Health Plan - Dental benefits​

SpanishFor MembersOHP 9035

Oregon Health Plan - Client Handbook​

EnglishFor MembersOHP 9035

Oregon Health Plan - Client Handbook​

EnglishFor MembersDMAP 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.​

EnglishFor MembersOHP 7208M

​Medicare Advantage Plan Election​

SpanishFor MembersOHP 7208M

​​Medicare Advantage Plan Election​

EnglishFor MembersOHP 7209

Request to Terminate Insurance​

EnglishFor MembersDMAP 390

Request to Change Pharmacy - For Pharmacy management Program clients​

EnglishFor MembersDMAP 3083

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

EnglishFor MembersDMAP 3086

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

EnglishFor MembersOHP 3001

OHP Complaint Form​

SpanishFor MembersOHP 3001

OHP Complaint Form​

EnglishFor MembersOHP 3360

Pregnancy Notification​

EnglishFor MembersMSC 415H

Insurance Notification Form​

EnglishFor MembersDMAP 3030

Notice of Hearing Rights​

EnglishFor MembersOHP 9035

Oregon Health Plan - Client Handbook (Large Print)​

RussianFor MembersOHP 9035

Oregon Health Plan - Client Handbook​

VietnameseFor MembersOHP 9035

Oregon Health Plan - Client Handbook​

RussianFor MembersDMAP 1418

Your Oregon Health Plan benefits

VietnameseFor MembersDMAP 1418

Your Oregon Health Plan benefits

VietnameseFor MembersOHP 7208M

Medicare Advantage Plan Election​

RussianFor MembersOHP 7208M

Medicare Advantage Plan Election​

EnglishFor MembersMail Order Prescription Form

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

SpanishFor MembersMail Order Prescription Form

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

EnglishFor MembersA&D Resource Directory

Oregon Alcohol & Other Drug Services Directory

EnglishFor MembersDMAP 527

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

SpanishFor MembersDMAP 3030

Notice of Hearing Rights​

RussianFor MembersDMAP 3030

Notice of Hearing Rights​

VietnameseFor MembersDMAP 3030

Notice of Hearing Rights​

EnglishFor MembersDMAP 3082

Oregon Health Plan Overview for Certified Families ​

RussianFor MembersOHP 3001

OHP Complaint Form​

VietnameseFor MembersOHP 3001

OHP Complaint Form​

RussianFor MembersOHP 3259

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

VietnameseFor MembersOHP 3259

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

EnglishFor MembersMSC 443

DHS/OHA Administrative Hearing Request Form​

SpanishFor MembersMSC 443

DHS/OHA Administrative Hearing Request Form​

RussianFor MembersMSC 443

DHS/OHA Administrative Hearing Request Form​

VietnameseFor MembersMSC 443

DHS/OHA Administrative Hearing Request Form​

EnglishFor MembersOHP 9040 - English

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

EnglishFor MembersOHP 9040A - English

Oregon Health Plan Client Tip Sheet 1 – Getting started

EnglishFor MembersOHP 9040B - English

Oregon Health Plan Client Tip Sheet 2 – Prior authorization​

EnglishFor MembersOHP 9040C - English

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

EnglishFor MembersOHP 9040D - English

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

EnglishFor MembersOHP 9040E - English

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

EnglishFor MembersOHP 9040F - English

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

EnglishFor MembersOHP 9040G - English

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

EnglishFor MembersOHP 9040H - English

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

EnglishFor MembersOHP 9040I - English

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

EnglishFor MembersOHP 9040J - English

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

EnglishFor MembersDMAP 1415

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

EnglishFor MembersDMAP 1415 (Large Print)

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

CambodianFor MembersDMAP 1415

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

KoreanFor MembersDMAP 1415

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

LaotianFor MembersDMAP 1415

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

RomanianFor MembersDMAP 1415

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

RussianFor MembersDMAP 1415

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

ChineseFor MembersDMAP 1415

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

SomaliFor MembersDMAP 1415

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

VietnameseFor MembersDMAP 1415

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

SpanishFor MembersDMAP 1415

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

EnglishFor MembersDMAP 1416

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.

EnglishFor Outreach SitesDMAP 6670

​Outreach Facility Update​

EnglishFor Outreach SitesOHA 3128

​Outreach Facility Application​​

EnglishFor Outreach SitesOHA 3274

Quarterly Report Form​

EnglishFor Outreach SitesOHA 6625

Order Form for Applications​

EnglishFor Outreach SitesDHS 5530

Combined Standards Chart (FPL)​

EnglishFor Outreach SitesDMAP 2410

Newborn Notification Form​

EnglishFor Outreach SitesOHP 3261

Inpatient Hospital Hold Request​ - Submit once per day via secure email to application.requests@state.or.us

EnglishFor Outreach SitesOHP 3360

Pregnancy Notification​

EnglishFor Outreach SitesMSC 415H

Insurance Notification Form​

EnglishFor Outreach SitesProvider Web Portal Eligibility Reference - To review inmate eligibility

Use the Provider Web Portal to review the Medicaid eligibility of inmates. You can search by SSN, name and date of birth if the Medicaid ID number is unknown.​

EnglishFor Outreach SitesDMAP 7100

Use this form to notify OHP Customer Service of eligible or potentially eligible inmates.

EnglishFor Outreach SitesMSC 2099

DHS|OHA Authorization for Use and Disclosure of Information​

EnglishFor Outreach SitesOHA 7210 - Family Application

Medical Assistance Family Application ​- Applicant should include self, spouse/domestic partner, children, anyone included on their federal income tax return

EnglishFor Outreach SitesOHA 7210 - Individual Application

Medical Assistance Individual Application - For one person who cannot be claimed as a dependent on someone else's tax returna nd does not live with spouse, child(ren) or have any tax dependents​

EnglishFor ProvidersDMAP 405T

Medical Transportation Order (for Transportation Brokerages)​

EnglishFor ProvidersDMAP 1074

Prior Authorization for Out-of-State Services​

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

Positioner Justification - Positioners for Standing​​

EnglishFor ProvidersDMAP 9033

Lead Risk Assessment Questionnaire​

EnglishFor ProvidersDMAP 2473

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

EnglishFor ProvidersDMAP 2472

Maternity Case Management - Home and Environmental Assessment​

EnglishFor ProvidersDMAP 3084 (PDF)

Request for Transplant or Transplant Evaluation​ (PDF)

EnglishFor ProvidersDHS 0189

Direct Deposit Authorization Form​

EnglishFor ProvidersDMAP 3035

Provider Information Update​

EnglishFor ProvidersDMAP 3113

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).​

EnglishFor ProvidersDMAP 3162

Oregon Automated Voice Response - Quick Reference Guide​

EnglishFor ProvidersDMAP 3161

How to read the Provider Web Portal eligibility verification screen​

EnglishFor ProvidersDMAP 3160

Provider Web Portal Quick Setup Guide​

EnglishFor ProvidersDHS 3970

EDMS Cover Sheet​

EnglishFor ProvidersDMAP 505

Medicare/Medicaid Billing Invoice​

EnglishFor ProvidersDMAP 1036

Individual Adjustment Request​

EnglishFor ProvidersDMAP 1419

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.​

EnglishFor ProvidersDMAP 3049

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​.

EnglishFor ProvidersDMAP 3085

Request for Administrative Review​

EnglishFor ProvidersDMAP 3083

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

EnglishFor ProvidersDMAP 3047

Augmentative Communication Device Selection Summary Report​

EnglishFor ProvidersDHS 3971
Oregon DHS Prior Authorization Request - instructions
EnglishFor ProvidersDMAP 2471

Maternity Case Management - Training and Education Tracking​

EnglishFor ProvidersDMAP 2470

Maternity Case Management - Initial Assessment​

EnglishFor ProvidersOHP 3360

Pregnancy Notification​

EnglishFor ProvidersMSC 415H

Insurance Notification Form​

EnglishFor ProvidersForm 42
Hospital Cost Settlement form and instructions
EnglishFor ProvidersDMAP 2461

Evaluation of Respiratory Assist Device​

EnglishFor ProvidersDMAP 742B
Ages 15-20 Consent to Sterilization
SpanishFor ProvidersDMAP 742B
Ages 15-20 Consent to Sterilization - Spanish
EnglishFor ProvidersDMAP 590

Private Duty Nursing Psychosocial Grid​

EnglishFor ProvidersDMAP 591

Private Duty Nursing Acuity Grid​

EnglishFor ProvidersDMAP 741

Hysterectomy Consent​

SpanishFor ProvidersDMAP 741

Hysterectomy Consent - Spanish​

EnglishFor ProvidersDMAP 742A

Consent to Sterilization​

SpanishFor ProvidersDMAP 742A

Consent to Sterilization - Spanish​

EnglishFor ProvidersDMAP 3131

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

EnglishFor ProvidersDMAP 3079

Notice of TPO Exemption to HIPAA Privacy Requirements​

EnglishFor ProvidersDMAP 2410

Newborn Notification​

EnglishFor ProvidersDMAP 3027

FQHC/RHC Cost Statement​ (PDF)

EnglishFor ProvidersDMAP 3027

FQHC/RHC Cost Statement​ (Excel)

EnglishFor ProvidersDMAP 525

Hospice in a Nursing Facility Notification Form​

EnglishFor ProvidersDMAP Provider Enrollment Forms

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

EnglishFor ProvidersDMAP 3130

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

EnglishFor ProvidersDMAP 3163

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

EnglishFor ProvidersDMAP 2120

OHA Provider Discrimination Review Request (Word)​

EnglishFor ProvidersDMAP 2120

OHA Provider Discrimination Review Request (PDF)​

EnglishFor ProvidersDMAP 3129

Provider Enrollment Attachment for Recognized Patient-Centered Primary Care Home (PCPCH) Providers (PDF) - See OAR 410-141-0860 for PCPCH enrollment requirements​

EnglishFor ProvidersDMAP 3129

Provider Enrollment Attachment for Recognized Patient-Centered Primary Care Home (PCPCH) Providers (Word) - See OAR 410-141-0860 for PCPCH enrollment requirements​

EnglishFor ProvidersDMAP 3046

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

EnglishFor ProvidersDMAP 3074

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​

EnglishFor ProvidersOHA 8705

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​

EnglishFor ProvidersDMAP 7204

​Substance Use Disorder Residential Treatment Facility Admission/Discharge Notification

EnglishFor ProvidersDMAP 3165 (Word)

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

EnglishFor ProvidersDMAP 3165 (PDF)

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

EnglishFor ProvidersOHP 7260 - PDF

​Application for Hospital Presumptive Eligibility

EnglishFor ProvidersOHP 3263A - PDF

​Approval Notice for Hospital Presumptive Eligibility

EnglishFor ProvidersOHP 3263B - PDF

​Denial Notice for Hospital Presumptive Eligibility

EnglishFor ProvidersOHP 7260 - Word

Application for Hospital Presumptive Eligibility​

EnglishFor ProvidersOHP 3263A - Word

​Approval Notice for Hospital Presumptive Eligibility

EnglishFor ProvidersOHP 3263B - Word

​Denial Notice for Hospital Presumptive Eligibility

EnglishFor ProvidersOHP 3262 (PDF)

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

EnglishFor ProvidersOHP 3262 (Word)

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

SpanishFor ProvidersDMAP 3165 (Word)

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

SpanishFor ProvidersDMAP 3165 (PDF)
OHP Client Agreement to Pay for Health Services (Spanish)​​
EnglishFor ProvidersDMAP 2405T

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

SpanishFor ProvidersDMAP 2405T

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

RussianFor ProvidersDMAP 3165 (Word)

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

RussianFor ProvidersDMAP 3165 (PDF)

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

VietnameseFor ProvidersDMAP 3165 (Word)

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

VietnameseFor ProvidersDMAP 3165 (PDF)

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

EnglishFor ProvidersDMAP 3804 (Word)

Request for Transplant or Transplant Evaluation (Word)​

EnglishFor ProvidersOHA 8061

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

EnglishFor ProvidersOHA 8057

Mental Health Plan of Care Request​

EnglishFor ProvidersOHA 8059

Psychosocial Rehabilitative Service Plan of Care Request (To be used for H2018HK)

EnglishFor ProvidersOHA 8060

Mental Health Prior Authorization Request Form​

EnglishFor ProvidersDMAP 531

Medicaid Personal Care Service Plan Authorization for Mental Health Services​

EnglishOHP Comparison ChartsOHP 9031BAKE

Baker County​

SpanishOHP Comparison ChartsOHP 9031BAKE

Baker County​

RussianOHP Comparison ChartsOHP 9031BAKE

Baker County​

VietnameseOHP Comparison ChartsOHP 9031BAKE

Baker County​

EnglishOHP Comparison ChartsOHP 9031BENT

Benton County​

SpanishOHP Comparison ChartsOHP 9031BENT

Benton County​

RussianOHP Comparison ChartsOHP 9031BENT

Benton County​

VietnameseOHP Comparison ChartsOHP 9031BENT

Benton County​

EnglishOHP Comparison ChartsOHP 9031CLAC

Clackamas County​

SpanishOHP Comparison ChartsOHP 9031CLAC

Clackamas County​

RussianOHP Comparison ChartsOHP 9031CLAC

Clackamas County​

VietnameseOHP Comparison ChartsOHP 9031CLAC

Clackamas County​

EnglishOHP Comparison ChartsOHP 9031CLAT

Clatsop County​

SpanishOHP Comparison ChartsOHP 9031CLAT

Clatsop County​

RussianOHP Comparison ChartsOHP 9031CLAT

Clatsop County​

VietnameseOHP Comparison ChartsOHP 9031CLAT

Clatsop County​

EnglishOHP Comparison ChartsOHP 9031COLU

Columbia County​

SpanishOHP Comparison ChartsOHP 9031COLU

Columbia County​

RussianOHP Comparison ChartsOHP 9031COLU

Columbia County​

VietnameseOHP Comparison ChartsOHP 9031COLU

Columbia County​

EnglishOHP Comparison ChartsOHP 9031COOS

Coos County​

SpanishOHP Comparison ChartsOHP 9031COOS

Coos County​

RussianOHP Comparison ChartsOHP 9031COOS

Coos County​

VietnameseOHP Comparison ChartsOHP 9031COOS

Coos County​

EnglishOHP Comparison ChartsOHP 9031CROO

Crook County​

SpanishOHP Comparison ChartsOHP 9031CROO

Crook County​

RussianOHP Comparison ChartsOHP 9031CROO

Crook County​

VietnameseOHP Comparison ChartsOHP 9031CROO

Crook County​

EnglishOHP Comparison ChartsOHP 9031CURR

Curry County​

SpanishOHP Comparison ChartsOHP 9031CURR

Curry County​

RussianOHP Comparison ChartsOHP 9031CURR

Curry County​

VietnameseOHP Comparison ChartsOHP 9031CURR

Curry County​

EnglishOHP Comparison ChartsOHP 9031DESC

Deschutes County​

SpanishOHP Comparison ChartsOHP 9301DESC

Deschutes County​

RussianOHP Comparison ChartsOHP 9031DESC

Deschutes County​

VietnameseOHP Comparison ChartsOHP 9031DESC

Deschutes County​

EnglishOHP Comparison ChartsOHP 9031DOUG

Douglas County​

SpanishOHP Comparison ChartsOHP 9031DOUG

Douglas County​

RussianOHP Comparison ChartsOHP 9031DOUG

Douglas County​

VietnameseOHP Comparison ChartsOHP 9031DOUG

Douglas County​

EnglishOHP Comparison ChartsOHP 9031GILL

Gilliam County​

SpanishOHP Comparison ChartsOHP 9031GILL

Gilliam County​

RussianOHP Comparison ChartsOHP 9031GILL

Gilliam County​

VietnameseOHP Comparison ChartsOHP 9031GILL

Gilliam County​

EnglishOHP Comparison ChartsOHP 9031GRAN

Grant County​

SpanishOHP Comparison ChartsOHP 9031GRAN

Grant County​

RussianOHP Comparison ChartsOHP 9031GRAN

Grant County​

VietnameseOHP Comparison ChartsOHP 9031GRAN

Grant County​

EnglishOHP Comparison ChartsOHP 9031HARN

Harney County​

SpanishOHP Comparison ChartsOHP 9031HARN

Harney County​

VietnameseOHP Comparison ChartsOHP 9031HARN

Harney County​

RussianOHP Comparison ChartsOHP 9031HARN

Harney County​

EnglishOHP Comparison ChartsOHP 9031HOOD

Hood River County​

SpanishOHP Comparison ChartsOHP 9031HOOD

Hood River County​

RussianOHP Comparison ChartsOHP 9031HOOD

Hood River County​

VietnameseOHP Comparison ChartsOHP 9031HOOD

Hood River County​

EnglishOHP Comparison ChartsOHP 9031JACK

Jackson County​

SpanishOHP Comparison ChartsOHP 9031JACK

Jackson County​

RussianOHP Comparison ChartsOHP 9031JACK

Jackson County​

VietnameseOHP Comparison ChartsOHP 9031JACK

Jackson County​

EnglishOHP Comparison ChartsOHP 9031JEFF

Jefferson County​

SpanishOHP Comparison ChartsOHP 9031JEFF

Jefferson County​

RussianOHP Comparison ChartsOHP 9031JEFF

Jefferson County​

VietnameseOHP Comparison ChartsOHP 9031JEFF

Jefferson County​

EnglishOHP Comparison ChartsOHP 9031JOSE

Josephine County​

SpanishOHP Comparison ChartsOHP 9031JOSE

Josephine County​

RussianOHP Comparison ChartsOHP 9031JOSE

Josephine County​

VietnameseOHP Comparison ChartsOHP 9031JOSE

Josephine County​

EnglishOHP Comparison ChartsOHP 9031KLAM

Klamath County​

SpanishOHP Comparison ChartsOHP 9031KLAM

Klamath County​

RussianOHP Comparison ChartsOHP 9031KLAM

Klamath County​

VietnameseOHP Comparison ChartsOHP 9031KLAM

Klamath County​

EnglishOHP Comparison ChartsOHP 9031LAKE

Lake County​

SpanishOHP Comparison ChartsOHP 9031LAKE

Lake County​

RussianOHP Comparison ChartsOHP 9031LAKE

Lake County​

VietnameseOHP Comparison ChartsOHP 9031LAKE

Lake County​

EnglishOHP Comparison ChartsOHP 9031LANE

Lane County​

SpanishOHP Comparison ChartsOHP 9031LANE

Lane County​

RussianOHP Comparison ChartsOHP 9031LANE

Lane County​

VietnameseOHP Comparison ChartsOHP 9031LANE

Lane County​

EnglishOHP Comparison ChartsOHP 9031LINC

Lincoln County​

SpanishOHP Comparison ChartsOHP 9031LINC

Lincoln County​

RussianOHP Comparison ChartsOHP 9031LINC

Lincoln County​

VietnameseOHP Comparison ChartsOHP 9031LINC

Lincoln County​

EnglishOHP Comparison ChartsOHP 9031LINN

Linn County​

SpanishOHP Comparison ChartsOHP 9031LINN

Linn County​

RussianOHP Comparison ChartsOHP 9031LINN

Linn County​

VietnameseOHP Comparison ChartsOHP 9031LINN

Linn County​

EnglishOHP Comparison ChartsOHP 9031MALH

Malheur County​

SpanishOHP Comparison ChartsOHP 9031MALH

Malheur County​

RussianOHP Comparison ChartsOHP 9031MALH

Malheur County​

VietnameseOHP Comparison ChartsOHP 9031MALH

Malheur County​

EnglishOHP Comparison ChartsOHP 9031MARI

Marion County​

SpanishOHP Comparison ChartsOHP 9031MARI

Marion County​

RussianOHP Comparison ChartsOHP 9031MARI

Marion County​

VietnameseOHP Comparison ChartsOHP 9031MARI

Marion County​

EnglishOHP Comparison ChartsOHP 9031MORR

Morrow County​

SpanishOHP Comparison ChartsOHP 9031MORR

Morrow County​

RussianOHP Comparison ChartsOHP 9031MORR

Morrow County​

VietnameseOHP Comparison ChartsOHP 9031MORR

Morrow County​

EnglishOHP Comparison ChartsOHP 9031MULT

Multnomah County​

SpanishOHP Comparison ChartsOHP 9031MULT

Multnomah County​

RussianOHP Comparison ChartsOHP 9031MULT

Multnomah County​

VietnameseOHP Comparison ChartsOHP 9031MULT

Multnomah County​

EnglishOHP Comparison ChartsOHP 9031POLK

Polk County​

SpanishOHP Comparison ChartsOHP 9031POLK

Polk County​

RussianOHP Comparison ChartsOHP 9031POLK

Polk County​

VietnameseOHP Comparison ChartsOHP 9031POLK

Polk County​

EnglishOHP Comparison ChartsOHP 9031SHER

Sherman County​

SpanishOHP Comparison ChartsOHP 9031SHER

Sherman County​

RussianOHP Comparison ChartsOHP 9031SHER

Sherman County​

VietnameseOHP Comparison ChartsOHP 9031SHER

Sherman County​

EnglishOHP Comparison ChartsOHP 9031TILL

Tillamook County​

SpanishOHP Comparison ChartsOHP 9031TILL

Tillamook County​

RussianOHP Comparison ChartsOHP 9031TILL

Tillamook County​

VietnameseOHP Comparison ChartsOHP 9031TILL

Tillamook County​

EnglishOHP Comparison ChartsOHP 9031UMAT

Umatilla County​

SpanishOHP Comparison ChartsOHP 9031UMAT

Umatilla County​

RussianOHP Comparison ChartsOHP 9031UMAT

Umatilla County​

VietnameseOHP Comparison ChartsOHP 9031UMAT

Umatilla County​

EnglishOHP Comparison ChartsOHP 9031UNIO

Union County​

SpanishOHP Comparison ChartsOHP 9031UNIO

Union County​

RussianOHP Comparison ChartsOHP 9031UNIO

Union County​

VietnameseOHP Comparison ChartsOHP 9031UNIO

Union County​

EnglishOHP Comparison ChartsOHP 9031WALL

Wallowa County​

SpanishOHP Comparison ChartsOHP 9031WALL

Wallowa County​

RussianOHP Comparison ChartsOHP 9031WALL

Wallowa County​

VietnameseOHP Comparison ChartsOHP 9031WALL

Wallowa County​

EnglishOHP Comparison ChartsOHP 9031WASC

Wasco County​

SpanishOHP Comparison ChartsOHP 9031WASC

Wasco County​

RussianOHP Comparison ChartsOHP 9031WASC

Wasco County​

VietnameseOHP Comparison ChartsOHP 9031WASC

Wasco County​

EnglishOHP Comparison ChartsOHP 9031WASH

Washington County​

SpanishOHP Comparison ChartsOHP 9031WASH

Washington County​

RussianOHP Comparison ChartsOHP 9031WASH

Washington County​

VietnameseOHP Comparison ChartsOHP 9031WASH

Washington County​

EnglishOHP Comparison ChartsOHP 9031WHEE

Wheeler County​

SpanishOHP Comparison ChartsOHP 9031WHEE

Wheeler County​

RussianOHP Comparison ChartsOHP 9031WHEE

Wheeler County​

VietnameseOHP Comparison ChartsOHP 9031WHEE

Wheeler County​

EnglishOHP Comparison ChartsOHP 9031YAMH

Yamhill County​

SpanishOHP Comparison ChartsOHP 9031YAMH

Yamhill County​

RussianOHP Comparison ChartsOHP 9031YAMH

Yamhill County​

VietnameseOHP Comparison ChartsOHP 9031YAMH

Yamhill County​

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