Provider Forms
General
- Authorization to use/disclose information (PHI) about a member
- 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 (Ages 15-20)
- Insulin Glargine New Prescription Template
- Provider Inquiry and Appeal Form
Programs
Flexible Services Request Form
Flexible 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. Members can take the form to their healthcare provider to fill out and submit.
Please use the online form to submit a Flexible Services request.
You can also complete the PDF version of flexible services and health related services request form.
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.
THW Referral Request Form
This form is designed to serve as a single, unified referral request for Traditional Health Workers (THWs). It helps identify member needs, suggest the appropriate THW type, and support care coordination.
Please use the online form to submit a THW referral request.
Classes
Community health worker training modules
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.
Credentialing
- Oregon Practitioner Credentialing Application
- Locum Tenens Form
- Oregon Practitioner Re-credentialing Application
- Moda Health Practice Survey
- Organizational Provider Credentialing Application
- 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
