Samples & Forms
Samples
Explanation of Benefits (EOB) (PDF File)
Payment Disbursement Register (PDR)
- Basic Claim (PDF File)
- Alternate Benefit (PDF File)
- Overpayment (PDF File)
- Wrong Patient Adjustment (PDF File)
Forms
Warning: Acrobat Reader does not allow you to save your completed forms; they must be printed.- Credentialing (PDF File)
- Recredentialing (PDF File)
- ODS Dental Claim (PDF File)
- Survey of Charges - General Dentist (PDF File)
- Survey of Charges - Endodontist (PDF File)
- Survey of Charges - Oral Maxillofacial Surgeon (PDF File)
- Survey of Charges - Orthodontist (PDF File)
- Survey of Charges - Pediatric Dentist (PDF File)
- Survey of Charges - Periodontist (PDF File)
Brochures & Guidelines
Oral Health, Total Health Enrollment
- Oral Health, Total Health Enrollment Form (PDF File)
oral health total health
total health oral health
total health, oral health
OHP Forms
- Interpreter Request (PDF File)
- Member Authorization (PDF File)
- Patient Responsibility Waiver (PDF File)
- Specialist Referral Request (PDF File)
OHP Brochures & Guidelines
These resources are available for your reference and can be printed and given to OHP patients.
- Immediate Denture Brochure (PDF
File)
This brochure will inform your patients about how to take care of immediate dentures and what to do after surgery. - Pregnancy and Your Teeth* (PDF
File)
This flyer emphasizes taking care of your teeth while you are pregnant. - Routine Visit Incentive Program - Malheur County members only (PDF
File) en Español
This brochure provides incentives for your patients who keep up routine visits. - Take Time for Teeth* (PDF
File)
This brochure informs parents on how to care for their young child’s teeth to prevent early childhood caries. - Talking with Your Provider* | Notes pages* (PDF
File)
Print out this resource and note pages to help you prepare for your visit and talk with your provider. The notes pages provides questions for you to ask your provider during your next visit.
*Spanish and English versions included in document