Medical Renewal Form Page 7
ADVERTISEMENT
1
2
3
4
5
6
7
8
9Case name:
Case number:
Date of request:
Coverage within
Coverage was lost
Coverage within the
Coverage within the last
the last two
because a parent lost
last two months was
two months was through
months was
a job, had their hours
through OMIP, FMIP or
Kaiser Permanente
through COBRA.
reduced or it was no
Family Health Insurance
Child Health Program
Yes No.
longer offered through
Assistance Program.
or Kaiser Transition
If yes, who?
work. Yes No
Yes No
Program. Yes No
If yes, who?
If yes, who?
If yes, who?
Is anyone in your home who is applying for benefits able to get insurance through an employer?
Yes No If yes, who? ______________________________________________________
4. Choosing a plan. There may be a Coordinated Care Organization, or CCO, available in your
community. CCOs are local networks of doctors, mental health providers, hospitals and other
providers. They work together for patient-centered care for people on the Oregon Health Plan
and Healthy Kids. Read more about CCOs at
We encourage you to choose a CCO and dental plan or a medical and dental plan. If you don’t
make a choice, we may choose for you. Before you pick, you might want to ask your doctor and
dentist which plans they accept. Read the list of plans at
Write your first and second choices for CCOs and dental or medical and dental plans below.
Sometimes the first choice is full. Depending on which program your children qualify for, we may
send you a letter asking you to choose another medical plan.
CCO - 1st choice
CCO - 2nd choice
Dental plan - 1st choice
Dental plan - 2nd choice
OR
Medical plan - 1st choice
Medical - 2nd choice
Dental plan - 1st choice
Dental plan - 2nd choice
5. American Indians and Alaska Natives who want to be enrolled in plans. American Indians,
Alaska Natives and people who have access to care through Indian Health Services may choose
to enroll into a Coordinated Care Organization (CCO) or a managed care plan where available.
You may also choose to be enrolled in a dental and/or mental health plan only. If you are
enrolled in a CCO or a managed care plan, you can still access services at Indian Health
Services, the Urban Indian Program or through the Tribal Health Clinic.
?
?
Need help?
Please call your worker. The phone number is at the top of the first page.
Page 7
OHA 0945 (06/12)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business