Health Authority Forms and Office Locations – Government Agency in Oregon

61 - 80 of 156 forms

Form Title	Topics
Hysterectomy Consent - Spanish
Impairment Severity Rating Report
Individual Adjustment Request
Law Enforcement Medical Liability Account (LEMLA) Claim - Enrolled Oregon Medicaid providers can complete this form with one year of date of injury and submit it to the law enforcement agency believed responsible
Lead Risk Assessment Questionnaire
MAC Local Match Leveraging Form - Unit of government providers use this form to submit local match prepayments for Medicaid Administrative Claiming (MAC) activities billed to DHS/OHA
Mail Order Prescription Form (English) - This service is for ongoing monthly prescriptions for services covered by OHP on a fee-for-service basis
Managed Care and CCO Provider Enrollment Form
Maternity Case Management - Five A's Intervention Record (FAIR) for Smoking Cessation
Maternity Case Management - Home and Environmental Assessment
Maternity Case Management - Initial Assessment
Maternity Case Management - Training and Education Tracking
Medicaid Personal Care Service Plan Authorization for Mental Health Services
Medical Record Checklist
Medical Transportation Order - To be authorized by local Transportation Brokerages
Medicare Advantage Plan Election
Medicare Advantage Plan Election (Russian
Medicare Advantage Plan Election (Spanish
Medicare/Medicaid Billing Invoice
Mental Residual Function Capacity Report

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