Forms

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 withall the required supporting information to: (503) 413-5864.

Please note: Adobe Acrobat Reader is required for these documents. Click here
for the latest version of Adobe Reader.

CareMark Comp MCO:

 

SPECIAL FORMS FOR:

City of Portland Fire and Police Disability and Retirement Fund (FPDR)

Attending Physicians Report (APR)

Work Status Report (WSR)

Intel

Intel Return to Work Activity Status Form

Other Forms

Physician Additional Information Form (.pdf)

2012 Oregon Practitioner Credentialing Application (.pdf)

2012 Oregon Practitioner Credentialing Application (.doc)

2012 Oregon Practitioner Recredentialing Application (.pdf)

2012 Oregon Practitioner Recredentialing Application (.doc)