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Assignment Referral Form

Assigning members to a Primary Care Provider 

All members are assigned to a primary care provider (PCP) shortly after their enrollment to FamilyCare Health. We currently offer members and PCPs a 120-day transition period, during which new patients can meet with the PCP of their choice, even if they’re not the assigned PCP. This gives us a chance to help members find a new plan or a new PCP. 

If you agree to see a FamilyCare Health member for a non-emergency regular office visit outside of this transition period and you aren’t the assigned PCP, the claim will be denied. If you call Provider Navigation Services prior to the appointment, we can assist in getting the member assigned to you so the claim for the care is approved. If you have any questions or concerns, please call our Provider Education Services at 503-222-2880 or 800-458-9518.  

Clinical Practice Guidelines

FamilyCare Health adopts practice guidelines, specified in 42 CFR 438.236 (b), (c) and (d), that are based on valid and reliable clinical evidence or a consensus of healthcare professionals and that consider the needs of Members in consultation with Participating Providers and reviews and updates them periodically as appropriate. FamilyCare Health recommends the following clinical practice guidelines to help practitioners and members make decisions about appropriate health care for specific clinical circumstances. See our Clinical Guidelines.


Not all services require authorization. Please refer to the links below to see if you need to submit a request. FamilyCare Health has a no retro authorization policy. Claims for services requiring prior authorization will be denied if rendered prior to receiving authorization.

Medicaid Services NOT Requiring Authorization

Medicare Services Requiring Authorization

Please note: You now have two ways to submit referrals and authorizations to FamilyCare Health:

  • Electronically, via PH Tech’s Community Integration Manager, or CIM
  • Via fax, after downloading and filling in by hand one of the forms below

Request Forms

Medical Services

Behavioral Health Services

Pharmacy Services

Other Requests

NIH applicants have the opportunity to suggest information to help NIH refer and review their grant application. When applying with the new FORMS-D application package, applicants will include their requests in the new assignment request form, rather than in the cover letter has has been done in the past.

Applicants should use the new assignment request form if they choose to:

  • request assignment to an institute/center for funding consideration
  • request assignment to a particular study section for initial peer review
  • identify individuals they do not think should review their application
  • identify scientific areas of expertise needed to review their application

Applicants should still use the cover letter attachment for information not captured on the assignment form, such as to provide information about a late application. Just like the cover letter, the assignment request form is only for internal use by receipt and referral staff and scientific review officers involved in handling the application’s review – we do not share the assignment request form or cover letter with reviewers or other NIH staff.

For more information, read these related NIH Guide notices:


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