Samples & Forms
Samples
Credentialing Forms
General forms
- Alcohol and/or Drug Dependence Screening - Adults & Adolescents
- Behavioral Health Treatment Plan--Psychiatrist/PMHNP
- Behavioral Health Treatment Plan--Therapist
- CMS (formerly HCFA) 1500 Claim
- Material Risk Notice
- Referral/Authorization (PDF File)
- Rx Preauthorization (PDF File)
Oregon Health Plan Forms
- Acupuncture Referral Request
- Bariatric Surgery Evaluation
- CMS (formerly HCFA) 1500 | Instructions
- Chemical Dependency Authorization Denial
- Drug Free Treatment Authorization Request (TAR)
- HIPAA Release
- Hysterectomy Consent
- Interpreter Request
- Patient Responsibility Waiver
- PCP Change
- Rx Preauthorization
- Referral/Authorization
- Sterilization Consent
- Sterilization Consent for 15-20 years old
- Synthetic Opiate Treatment Services Change in Client Status Information
- Synthetic Opiate Treatment Authorization Request