We provide comprehensive healthcare services to Hillsboro and surrounding communities.

Forms

THA requires the following forms to be submitted to request a referral to a non-THA specialist, a non-formulary medication, or medical equipment. For help with any of these forms, please call our Referral Coordinators at: 503-844-8104.

THA PCP/Specialist Referral Form 

This form must be used for all THA member referrals and procedure pre-authorizations. The form must be filled out completely and accurately to ensure timely processing. The form should include at a minimum:

Download THA PCP/Specialist Referral Form (PDF) »

THA Drug Prior Authorization Form

This form must be used for all THA member medication pre-authorizations. The form must be filled out completely and accurately to ensure timely processing. The form should include at a minimum:

Download THA Drug Prior Authorization Form (PDF) »

 

THA Durable Medical Equipment Prior Authorization Form

This form must be used for all THA member medical equipment pre-authorizations. The form must be filled out completely and accurately to ensure timely processing. The form should include at a minimum:

Download THA Durable Medical Equipment Prior Authorization Form (PDF) »

 

THA Flexible Services Request Form

Flexible Services are health related non-billable services intended to improve care delivery and Oregon Health Plan (OHP) Medicaid member health. Flexible services are unable to be reported using CPT or HCPCS codes. If a service has a CPT or HCPCS code, it may not be provided using Flexibles Services even if it is not a covered benefit.

Flexible Services are cost effective alternatives to traditional services and may include, but are not limited to, classes, programs, equipment, appliances or special clothing or footwear.

Examples of Flexible Services, per Oregon Health Authority, include, but are not limited to:

To request Flexible Services for a Health Share/Tuality Member:

Download THA Flexible Services Request Form (PDF) »