Oregon Health Authority Forms

This form is used for reporting induced termination of pregnancy in the state of Oregon.

This Form is used for renewing an Oregon OHP (Oregon Health Plan) eligibility.

This Form is used for renewing an Oregon Health Plan coverage for Russian-speaking individuals.

This form is used for applying for Oregon Health Plan benefits in the state of Oregon.

This document is a loan agreement form for a multi-user electric breast pump in the state of Oregon. It allows individuals to borrow and use the breast pump for a specific period of time.

This form is used for authorizing the disclosure, sharing, and use of individual information in the state of Oregon. It is specifically intended for individuals who understand and can read Russian.

This form is used for authorizing the disclosure, sharing, and use of individual information in the state of Oregon. It allows individuals to give consent for their personal information to be shared and used by specific parties or organizations.

This form is used for requesting a religious exception to receiving the Covid-19 vaccine in the state of Oregon.

This Form is used for requesting prior authorization for out-of-state services in Oregon.

This document is used for a supplemental rebate agreement in the state of Oregon. It outlines additional terms and conditions regarding rebates.

This form is used for appointing a health care representative and alternate health care representative in the state of Oregon. It allows individuals to designate someone to make medical decisions on their behalf if they are unable to do so themselves.

This form is used for naming a primary and alternate healthcare representative in Oregon.

This form is used for ordering transportation services under the Oregon Health Plan. It allows individuals to request transportation for medical appointments or other healthcare needs.

This form is used for American Indian/Alaska Native individuals to request a change in their enrollment status for the Oregon Health Plan in Oregon.

This form is used for documenting the five A's intervention record in Oregon's maternity case management program for smoking cessation.

This Form is used for conducting home and environmental assessments as part of maternity case management in the state of Oregon.

This form is used for local match leveraging in the Oregon Medical Assistance Program (MMAP). It helps leverage funds from local sources to support the program.

This Form is used for tracking and education purposes related to maternity case management in Oregon.

This form is used for conducting an initial assessment for maternity case management in the state of Oregon.

This form is used for notifying the Oregon Health Plan about a pregnancy. It is required for individuals who are enrolled in the plan and become pregnant.

This Form is used for filing a medical liability claim for law enforcement agencies in Oregon. It helps individuals seek compensation for medical expenses resulting from incidents involving law enforcement officers.

This form is used for requesting an administrative hearing in the state of Oregon. It can be used to appeal a decision made by a government agency or dispute a penalty or fine.

This form is used for submitting a coversheet for electronic documents in Oregon.

This form is used for designating an authorized representative and alternate payee in the state of Oregon.

This Form is used for individuals in Oregon to request an adjustment to their taxes or other financial matters. It allows individuals to make changes or corrections to information previously reported to the Oregon Department of Revenue.

This form is used for filing a complaint with the Oregon Health Plan. The form allows individuals to report any issues or concerns they may have with their health plan.

This type of document is a Complaint Form for the Oregon Health Plan in Oregon. It is used to file complaints regarding the healthcare plan in Spanish.

This form is used for documenting transplant or transplant evaluation requests in the state of Oregon.

This form is used for summarizing the selection report for augmentative communication devices in Oregon.

This form is used for clients in Oregon to agree to pay for pharmacy services provided by OHP (Oregon Health Plan).

This form is used for filing complaints against providers and partners of the Oregon Health Plan.

This form is used for an Ohp client in Oregon to agree to pay for health services.

This form is used for notifying individuals of their approval for temporary coverage under the Oregon Health Plan. It is specifically tailored for residents of Oregon who speak Somali.

This document is used to notify individuals in Oregon, who speak Chinese, about their approval for temporary coverage under the Oregon Health Plan.

This form is used for informing individuals about the denial of their temporary Oregon Health Plan coverage in Oregon.