Your Forms

You or Your Provider May Need These Coverage-related Forms

Accident/Injury ReportUse this form to report information regarding an accident or injury for claim processing.
Appeal Request Form
Appeal Request Form – Spanish
Ask IHN-CCO to change a decision made about your medical coverage.
Authorized Representative Form 
Use this form to grant someone permission to speak with us on your behalf. This form will allow your representative to file an appeal or grievance, as well as request services or communication regarding your care coordination, benefits, claims and other health information.
Care Coordination Request FormAs a new member, you may have questions or concerns about your ongoing care needs. Use this form to enroll in the Care Coordination Program.
Complaint Grievance Form
Complaint Grievance Form (Spanish)
Use this form to file a complaint or grievance with IHN-CCO. 
Dental Plan Choice Card
Dental Plan Choice Card (Spanish)
Choose or change your dental plan.
Flexible Services Request Form
Flexible Services Request Form (Spanish)
Request health-related services that OHP does not cover.
Review the Flexible Services Instructions (Spanish Instructions).
Hearing Request FormRequest an administrative hearing from the Department of Medical Assistance Programs (DMAP).
Medication ExceptionRequest medically necessary medications that are not normally covered on our formulary. Or request medications that request prior authorizations.
 Prescription Reimbursement FormSubmit this form with a receipt to the claims administrator for payment.
Primary Care Provider (PCP) Change Card
Primary Care Provider (PCP) Change Card (Spanish)
Choose or change your primary care provider.
Prior Authorization – Referral FormRequest a prior authorization for medical services you want IHN-CCO to cover.
Physician Incentives BrochureLearn how IHN-CCO pays a provider or group of providers.
 Record Request Form Use this form if you are a member or someone other than the member (or their legal representative) and need to request a copy of the member’s record for which the member’s authorization is required.
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