Samaritan :: Forms

Provider Home Page Summary of Benefits Forms Formulary Provider Directory Pharmacy Directory Request Information

Links to other sites:

Centers for Medicare and Medicaid Services (CMS): www.cms.hhs.gov Medicare www.medicare.gov Samaritan Health Services (SHS): www.samhealth.org Social Security Administration (SSA): www.ssa.gov

Forms

Below we have provided you with an electronic copy of the forms that will help coordinate the care of our members and your patients. All forms are in a MS Word and Adobe Acrobat Reader printable format for easy use. Get Acrobat Reader here for free .


	Interpreter Form

	Sample Beneficiary Insurance ID Card

	Appeal Rights

	Practice Guidelines

	Advance Directive

	Waiver of Liability

	List of Services Requiring an Authorization

	Appointment of Representative Statement

	Contact Us \| Patient Privacy Policy \| Terms of Use

Beneficiaries of Samaritan Advantage Health Plan must have Medicare Part A and Part B and must continue to pay Medicare premiums.
Enrolled beneficiaries must use Samaritan Advantage health Plan contracted providers for routine care.
Samaritan Advantage Health Plan is an HMO with a Medicare Advantage Contract.