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Forms
The following CareMark PPO and CareMark Comp MCO
Precertification Forms are now available in fillable .pdf format which
allow users to
FILL-IN the
necessary information by computer and
PRINT
ONLY.
These forms cannot be e-mailed or submitted
through the MHN website.
These forms can also be printed and completed by hand and then faxed as
well.
As always, we require completed precertification forms to be faxed with
all the required supporting information to: (503) 413-5864.
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Please note:
Adobe Acrobat Reader is required for these documents.
Click here
for the latest version of Adobe Reader. |
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CareMark PPO:
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CareMark PPO Precertification Form
CareMark Comp MCO:
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Precertification Form for Chiropractic, Osteopathic Manipulation, PT, OT
(functional), and Hand Therapy
Click
here for instructions on the form above
·
Precertification Form for Acupuncture, Massage, Speech-Lang Pathology,
OT (cognitive), Vision Therapy, Pain Program and Work
Hardening.
Click
here for instructions on the form above
· Precertification Form for Surgery, DME and Diagnostic Imaging
Special Forms for:
City of Portland Fire and Police Disability and Retirement Fund
(FPDR)
Attending Physicians Report
(APR)
Work
Status Report (WSR)
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