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.

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