Samaritan Select

Member forms

The following forms need to be turned into your local Samaritan Human Resources Department for approval.

• Group Health Enrollment Application: add family members or dependents to Samaritan Choice Plans and/or change your health plan options. Review the eligibility section of your Plan Document for a description of who is eligible and when to enroll on pages 14-17.
• Affidavit of Domestic Partnership: add a person to the health plan as a Domestic Partner if criteria have been met.
• Group Dental and Vision Application: change your dental provider or add a dependent onto your Dental and/or Vision plan.
• Coverage Termination: terminate coverage for yourself or a dependent.
• Declination of Coverage: decline coverage during open enrollment. NOTE: this form can only be used if you have proof of other coverage.

The following forms should be faxed or delivered to Samaritan Choice Plans. See individual form for appropriate fax number.

• Member Reimbursement Claim: request reimbursement for services that you have received and paid for that are a covered benefit of SCP.
• Prescription Reimbursement Claim: request reimbursement for prescriptions obtained at a non-participating pharmacy.
• Coordination of Benefits: to properly process your claims, Samaritan Choice Plans needs periodic updates regarding your other health insurance coverage.
• Disabled Dependent Certification: request continuance of coverage for a dependent that is reaching the limiting age of coverage.
• Out of Area Benefit Determination: request preferred benefits and prior authorization for services provided by a non-preferred provider. Preferred benefits are authorized only when certain criteria are met.