Member forms

OHP Application Form

You can apply for the Oregon Health Plan (OHP) by downloading and filling out this application, or you can apply online at One.Oregon.gov. Learn more about eligibility and applying for OHP.

OHP Application Form

Member Protected Health Information (PHI) Release Request Form

Use this form to give your consent to use and disclose your PHI.

Authorization for Disclosure of Protected Health Information (PHI) form (pdf)
DownloadAuthorization for Disclosure of Protected Health Information (PHI) form (143 KB)
Authorization for Disclosure of Protected Health Information (PHI) form Spanish (pdf)
DownloadAuthorization for Disclosure of Protected Health Information (PHI) form Spanish (159 KB)
Release of Information form (PHI) Arabic (pdf)
DownloadRelease of Information form (PHI) Arabic (189 KB)
Release of Information form (PHI) Russian (pdf)
DownloadRelease of Information form (PHI) Russian (216 KB)
Release of Information form (PHI) Simplified Chinese (pdf)
DownloadRelease of Information form (PHI) Simplified Chinese (225 KB)
Release of Information form (PHI) Somali (pdf)
DownloadRelease of Information form (PHI) Somali (136 KB)
Release of Information form (PHI) Traditional Chinese (pdf)
DownloadRelease of Information form (PHI) Traditional Chinese (237 KB)
Release of Information form (PHI) Vietnamese (pdf)
DownloadRelease of Information form (PHI) Vietnamese (172 KB)

Member Appointment of Representative Form

This form authorizes a person to be your representative, to act on your behalf to make all decisions related to your CareOregon coverage.

Member Request to View Claim Records Form

Use this form to request copies of your medical records.

English

Download

Complaint and Feedback Form

Use this form to submit a formal complaint or feedback about CareOregon. Learn more about filing a complaint.

OHP Newborn Notification Form

Right after your baby is born, you’ll need to use this form to enroll your newborn in the Oregon Health Plan (OHP). Enrollment is not automatic. Learn more on our Pregnancy and family support page.

OHP Newborn Notification Form

WIC Interest Form

If you are interested in the WIC program, you can find an interest form on the OHA website. Learn more on our Pregnancy and family support page.

WIC Interest Form

Care Coordination Self-Referral Form

Use this form to start the process of getting Care Coordination. Learn more on our Care Coordination services page.

Care Coordination Self-Referral Form

Member Handbook

Look at your member handbook for instructions on how to submit appeals.

Health Share Member Handbook

Pharmacy forms and documents

Direct Member Reimbursement Form

Use this form to ask us to pay you back for pharmacy and prescription purchases.

English

Download

Member COVID-19 At Home Test Reimbursement Form

Use this form to ask us to pay you back for FDA-authorized COVID-19 test kits you bought at a retail store, pharmacy or online retailer.

English

Download

Optum New Prescription Mail-In Order Form

Have your drugs delivered directly to your door by filling out this order form with Optum Mail Order Pharmacy.

English

Download

Formulary (Drug list)

See if your prescription drugs are included on our drug list and if there are any special rules or limitations. View the digital formulary and learn more on our Medications page.

English

Download

Health Related Social Needs (HRSN)

Please visit our Social needs assistance page to learn how to apply for free air conditioners, heaters, food, housing support and more.

Transportation forms

Please visit our Transportation assistance page to learn more about the free program Ride to Care, that can provide free transportation to non-emergency medical appointments.

Ride to Care Appointment of Representative Form

This form authorizes a person to be your representative, or to act on your behalf during any part of the non-emergency medical transportation (NEMT) process.

NEMT Appointment of Representative Form Somali

Oct 26, 2023, 16:55 by Lydia Weisshaar

Download (pdf) 180 KB

Consent for Secure Transportation Form

This form is used to provide written consent for secure transport, when required.

CO Secure Transport Consent Form (pdf)
DownloadCO Secure Transport Consent Form (209 KB)
CO_secure_transport_consent_form_arabic (pdf)
DownloadCO_secure_transport_consent_form_arabic (191 KB)
CO_secure_transport_consent_form_russian (pdf)
DownloadCO_secure_transport_consent_form_russian (215 KB)
CO_secure_transport_consent_form_simplified_chinese (pdf)
DownloadCO_secure_transport_consent_form_simplified_chinese (283 KB)
CO_secure_transport_consent_form_somali (pdf)
DownloadCO_secure_transport_consent_form_somali (212 KB)
CO_secure_transport_consent_form_spanish (pdf)
DownloadCO_secure_transport_consent_form_spanish (211 KB)
CO_secure_transport_consent_form_traditional_chinese (pdf)
DownloadCO_secure_transport_consent_form_traditional_chinese (301 KB)
CO_secure_transport_consent_form_vietnamese (pdf)
DownloadCO_secure_transport_consent_form_vietnamese (199 KB)

Other forms

CareOregon Community Advisory Board (COCAB) Application Form

If you are interested in serving on our Community Advisory Board, please complete this form. Learn more at Community Advisory Board (COCAB).

COCAB Application Form

Member forms and documents

Member forms

OHP Application Form

Member Protected Health Information (PHI) Release Request Form

Member Appointment of Representative Form

Member Request to View Claim Records Form

Complaint and Feedback Form

OHP Newborn Notification Form

WIC Interest Form

Care Coordination Self-Referral Form

Member Handbook

Pharmacy forms and documents

Direct Member Reimbursement Form

Member COVID-19 At Home Test Reimbursement Form

Optum New Prescription Mail-In Order Form

Formulary (Drug list)

Health Related Social Needs (HRSN)

Transportation forms

Ride to Care Appointment of Representative Form

NEMT Appointment of Representative Form Somali

Consent for Secure Transportation Form

Other forms

CareOregon Community Advisory Board (COCAB) Application Form

Related pages