Samaritan Select

Member Forms

Medication Exception/Prior Authorization: If it is medically necessary for you to have a non-formulary or brand medication, you may request a medication exception to have the medication covered or the co-pay lowered. The prescribing physician or your medical home physician will need to complete this form and fax it to Samaritan Select at (541) 768-4294. For questions please call the Samaritan Pharmacy Line at (541) 768-5207 or toll free at 1-888-435-2396.

Member Reimbursement Claim: Use this claim form to seek reimbursement for health care services for which you have paid.

Prescription Reimbursement Claim: Use this claim form to seek reimbursement for prescriptions obtained at a non-participating pharmacy. For questions please call the Samaritan Pharmacy Line at (541) 768-5207 or toll free at 1-888-435-2396.

Samaritan Pharmacy Services mail order prescription forms:

• FAX Order - Provide this form to your physician to fax your prescription to Samaritan Health Services.
• Registration/Prescription Order - Use this form when you have a written prescription that you are mailing to Samaritan Health Services.
• Prescription Transfer Request - Use this form to conveniently transfer all your prescriptions to Samaritan Health Services. We will contact the pharmacies you list on the form for you and have the prescriptions transferred.