Submitter Contact Information

What you need to know about reporting as a "CCO/DCO". This option is used by OHA contracted CCOs/DCOs to request a Lien Assignment. The Submitter must be either an employee of the CCO/DCO or an employee of the CCO's/DCO’s contracted subrogation firm. They will be the person we contact if we have questions. They also receive the confirmation email after this form is submitted.

First Name

Middle Initial

Last Name

Phone Number

Extension

Email Address

Why do we need your email address?

Your Relationship to the Injured Person

CCO/DCO Information

Coordinated Care Organization/Dental Care Organization Name

Please enter the CCO's/DCO's email address. If a lien assignment is approved, PIL will send the lien assignment to this email
address.

Type of CCO/DCO Submission

Why do we need this information?

Steps

Submitter Info
Injured Person
Responsible Party
Accident Info
Docs & Comments
Review & Submit