OAR 836-050-0115: Permitted Modifications to Uniform Forms

(1) An insurer may add to the face of the form its own identification and similar information, including insurer name and logo and policy identification by color coding or otherwise. The captions may be supplemented by instructions that merely facilitate the completion of the form. (2) An insurer may add to the back of the form or, for Exhibit 2, to any blank area on the face of the form, an item whose purpose is the certification of the status of the patient as a person in the insured group or as a member of the family or dependent of a person in the insured group. In the case of a claim form required by a state agency, the back of the form may also contain such provider certification and acknowledgment language as is required or permitted by law. (3) No alteration may be made to the format of the face of the form. No addition to the form may impose any additional requirement on any person, except for the certification item permitted by section (2) of this rule. (4) An insurer may screen the portions of the uniform claim form that it does not require to be completed, if the screening is done in such a way as to leave these portions usable by others. [ED. NOTE: Exhibits referenced are available from the agency.]