Forms - Oregon Providers - Clear Choice Health Plans

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Oregon Providers

Provider Resources - Forms

COIHS

		DME Authorization Form

		Preauthorization & Specialty Referral Form

		Home Enteral / Parenteral / IV Therapy Authorization Form

		Skilled Nursing Facility Services Request Form

		Outpatient Therapy Authorization Form

Commercial

		DME Authorization Form

		Preauthorization & Specialty Referral Form

		Home Enteral / Parenteral / IV Therapy Authorization Form

		Skilled Nursing Facility Services Request Form

General

		Provider Appeal Request Form

Medicare Advantage

		DME Authorization Form

		Preauthorization & Specialty Referral Form

		Home Enteral / Parenteral / IV Therapy Authorization Form

		Skilled Nursing Facility Services Request Form

		Outpatient Therapy Authorization Form

		Waiver of Liability Form