Enrollment Application Form

* Required Field
server side code uses target_organization to determine which organization code to send to the leads server. Note: both name and id must be set to target_organization

Your Information:

Format: mm/dd/yyy
Please note that this is how we will deliver your reward dollars and communicate with you throughout the program.
You can find your Member ID on your member card:



Where will you be receiving prenatal services? (Check all that apply)

Now we have some legal things to cover.

Statement of Terms.

I understand this is a voluntary program, and that it provides more benefits than the benefits that Columbia Pacific CCO usually offers. Columbia Pacific CCO and/or Amazon.com have the right to cancel First Steps at any time. I understand that I will be considered as actively enrolled in the program only after I have signed and submitted a Disclosure of Protected Health Information (PHI) form, and after I’ve received a letter from Columbia Pacific CCO stating that I have active status in the program.

I understand that the maximum reward that I can receive per year is $450.




Disclosure of Protected Health Information (PHI)

Please read our Consent Form for Protected Health Information (PHI) below. If you consent to disclose your PHI during the time we consider you as enrolled in First Steps, click the “I Consent” button below.

My authorization for disclosure of Protected Health Information (PHI):

Information about you and your health, called Protected Health Information, or “PHI,” is sensitive. Health plans, such as Columbia Pacific Coordinated Care Organization (CPCCO), cannot use your PHI or disclose it to anyone unless you say in writing that is OK with you. This form gives us your OK, or consent, to use and disclose your PHI specifically for the purpose of the First Steps Program. For your consent to be valid, you must click the “I consent” button and type your name below. You must do this to take part in the First Steps program, which offers benefits beyond the usual ones that Columbia Pacific CCO offers.

I give my consent to Columbia Pacific CCO and its First Steps program to use my Protected Health Information (PHI) specifically for the purposes of the First Step Program and disclose it, as is needed, to affiliates or third parties under contract with Columbia Pacific CCO or its affiliates to administer this reward program and distribute reward dollars for me to redeem. I acknowledge and understand that entities involved in this program may be aware I’m a pregnant member of Columbia Pacific CCO, a Medicaid company.



I understand my rights about this consent form:

I understand that, as the patient, my Protected Health Information (PHI) is protected by state and federal laws and regulations. I understand that this authorization is voluntary. I understand that Columbia Pacific CCO will not make this authorization a condition of providing treatment or payment I can ask for someone from Customer Service at Columbia Pacific CCO to help me understand how this form will be used.

I don’t have to sign this form to get health care, to have my health care paid for, to learn if I am eligible for benefits or to enroll in Columbia Pacific CCO.

I can revoke this authorization in writing except when Columbia Pacific CCO has already relied on it and taken action. I am free to change my mind and cancel my permission at any time. If I do change my mind, I must let Columbia Pacific CCO know in writing. I will send a letter to:

First Steps Program
CareOregon
315 SW Fifth Ave.
Portland, OR 97204

If I change my mind and cancel this consent, I understand that my PHI may have already been used or given out.

Submit

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