Managed HealthCare Northwest, Inc. 
      A Company of Legacy Health and Adventist Medical Center
 


 

 

 

 

 

 

 

 

 

 

 

 

 





      
   

 

Forms

Precertification forms:
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1. Universal Precertification Form
    (CareMark PPO and CareMark Comp MCO)

2. CareMark PPO Precertification Form

CareMark Comp MCO
3. Physical Medicine Precertification - Form 1

4. Physical Medicine Precertification - Form 1 Instruction Sheet

5. Physical Medicine Precertification - Form 2

6. Physical Medicine Precertification - Form 2 Instruction Sheet
 

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Special Forms for:
City of Portland Fire and Police Disability and Retirement Fund (FPDR)		  

Attending Physicians Report (APR)

Work Status Report (WSR)