This system is used to report an accident or incident that caused an injury to an individual who was covered by Medicaid/OHP or is a TANF (Temporary Assistance to Needy Families) applicant/participant.

Notice: You will need a current browser – such as Chrome, Mozilla Firefox, or Internet Explorer versions 9 or higher.

Please note: For security reasons, this form will timeout after 20 minutes of inactivity.

It may be helpful to have the following information ready before completing this form:

Oregon Health ID / Medicaid ID number of the individual(s) involved in the accident or incident
Date and location of the accident
Date of birth of the injured individual(s)
Insurance or attorney information (if applicable)

Client

Choose this button if you are reporting for yourself or are acting on behalf of a Medicaid/OHP recipient or TANF participant as their relative, guardian, authorized representative, case worker, conservator, agent, or you have their Power of Attorney.

Attorney

Choose this button if you are the Attorney or reporting for the Attorney who is representing the injured person and their dependants OR the attorney representing the Defendant (Tortfeasor).

CCO / DCO

Choose this button if you are reporting for a Coordinated Care Organization (CCO) / Dental Care Organization (DCO) and are requesting a lien assignment.

Adjuster

Choose this button if you are the Insurance Adjuster or reporting for the Insurance Adjuster who is representing the injured person and/or their dependants or the person responsible for the accident/injury.

Note: You will have an opportunity to print or save a copy of your submission after submitting this form.

Quick tip: Selecting a Submitter type above will allow you to continue to the next step.