Provider Forms

General

• Authorization to use/disclose information (PHI) about a member
  • From EOCCO
  • From EOCCO en Español
  • From provider or hospital

• Bariatric Surgery Evaluation
• CMS (formerly HCFA) 1500
• Declaration for Mental Health Treatment Form
• Patient Responsibility Waiver
• Patient Responsibility Waiver en Español
• Behavioral Health Authorization Form
• Psychological and Neuropsychological Evaluation Behavioral Health Authorization Form
• Out of Network (OON) Provider Behavioral Health Authorization Form
• EOCCO Flexible Services Request form (Health Related Services)
• Hysterectomy Consent form
• Hysterectomy Consent form en Español
• Sterilization Consent
• Sterilization Consent en Español
• Sterilization Consent for 15-20 year olds 
• Sterilization Consent for 15-20 year olds en Español
• Insulin Glargine New Prescription Template

Programs

• Cribs for Kids

Flexible Services Request Form (Health Related Services)

Health related services are non-covered services under OHP with goals to improve the way members get care and improve their health. These services are in addition to covered services and benefits under EOCCO. There are two kinds of health related services, flexible services and community benefit initiatives. Members can take the form to their healthcare provider to fill out and submit.

Please see the flexible services and health related services request form for more information.

Health Related Social Needs (HRSN)- Climate Devices

Health Related Social Needs (HRSN)- Climate Devices

Beginning on March 1, 2024, EOCCO members facing some specific life transitions may be able to get devices that help with healthy living environments. Devices may include air conditioners, heaters, air filtration devices, mini refrigeration units for storing medications and portable power supplies to operate medical equipment.

If your patient is a part of one of the groups below they may be able to get one or more of these devices:

• Adult or youth released from incarceration in the past 12 months
• Adult or youth discharged from Institutions for Mental Disease (IMDs) in the past 12 months
• Individual who is currently or who has previously been in the Oregon child welfare system
• Individual transitioning from Medicaid-only to dual eligibility (Medicaid and Medicare) status within the next three months or past nine months
• Individual who is homeless or at-risk of becoming homeless

In order to request a device at no cost, can click on the button below to fill out the form. Once you submit, you will get a confirmation message. You will then get an email with a request number once we start working on your request. We will send you an email update and send out a letter in the mail once a decision has been made, letting you know if your request was approved or denied.

Before filling out the form, please make sure you have:

• The member’s Medicaid member ID (you can find this on the front of your EOCCO/OHP ID card)
• The address for where we should ship/mail the requested devices.

If we determine that your patient is not eligible for fulfillment through HRSN, we will internally refer this request to HRS/Flex. No additional information will be needed from you.

  EOCCO Climate Device Request Form (smartsheet.com)

Classes

FREE Online Pain School for EOCCO Members

This class is intended to help individuals better understand chronic pain, increase confidence in dealing with pain, and provide a range of options to consider for treatment.

The program is full of useful tips, techniques and resources to get you moving down the path toward feeling more in control and hopeful despite living with pain. Each session lasts one hour and includes downloadable documents that will be completed in class throughout the four-week program. 

• Pain School Flyer

Community health worker training modules

• Poverty and related social determinants of health
• Management of chronic health conditions

Oregon community health worker training

An innovative online Community Health Worker (CHW) online and on-site training program is designed to support progress in public health outcomes for Eastern Oregonians.

• All Programs
• John Day Program

Credentialing

• Oregon Practitioner Credentialing Application
• Locum Tenens Form
• Oregon Practitioner Re-credentialing Application
• Moda Health Practice Survey
• Organizational Provider Credentialing Application
• DMAP Enrollment Form
• Hospital Based Enrollment Form
• Practitioner Rights
• Ownership or Control Interests Disclosure Form

• Provider diversity data - submit diversity, equity, and inclusion focused information for yourself (contracted practitioners)
• Clinic diversity data - submit diversity, equity, and inclusion focused information for contracted clinics/facilities

Eligibility

• PCP Change Form
• PCP Change Form (fax)
  
• Pregnancy Notification
• Newborn Notification Form
• Other Health Insurance