Forms, Downloads & Links

Brokers

Downloads & Links

• Authorization for Use and Disclosure of Protected Health Information

  Specify who can receive your health information and exactly what information that they can receive with this simple form.

• FSA/HRA Forms

  Find all the forms you need in one place regarding FSA and HRA information. Find dependent care claim forms, pricing sheets, and other helpful resources.

• General Forms

  Gain access to various forms you'll use such as group renewal confirmation forms, medical change forms, prior carrier credit forms, and more.

• Member Enrollment Packet

  These member enrollment forms will provide quick and easy onboarding for your new clients. Equip them with knowledge of PHP, how to use the online provider directory, understand where forms are located, and more.

• Sample Plan Options

  Browse sample plans and sample certificates of coverage for a variety of our different health insurance plan categories, including:  HMOs, Point of Service, and High Deductible plans.

Media/Press

Downloads & Links

• PHP Brand Guidelines

  Learn in more detail about PHP's primary and secondary colors, logo formats, and other branding guidelines.

• PHP Logo - Digital

  Here you will find PHP's official logo in horizontal format for your online use.

• PHP Logo - Print

  Here you will find PHP's official logo in horizontal format at print quality resolution.

Members

Downloads & Links

• 1095-B FAQ

  PHP will NOT be mailing individual policyholder Form 1095-B for 2019. Click to learn more.

• Authorization for Use and Disclosure of Protected Health Information

  Specify who can receive your health information and exactly what information that they can receive with this simple form.

• Be a Flu Fighter
• Centers for Medicare & Medicaid Services

  These links will direct you to government-based Web sites that include detailed information on HIPAA and related healthcare issues.

• Coordination of Benefits Request Form
• Medical Dictionary

  Medical jargon can be difficult to understand if you're not around it all the time. This medical dictionary can help you understand frequently used terms, different kinds of tests, and more.

• Medical Treatment Consent Form

  Leaving your child with a babysitter or family member may mean they won't receive care without your consent. This will ensure that in an emergency, your child will receive prompt, necessary medical care even if you are not there.

• Student Coverage Form
• Symptom Checker

  Know your symptoms? Check out what they might mean with this helpful tool. As always, be sure to consult your family doctor if symptoms get worse.

• United States Department of Health & Human Services

  These links will direct you to government-based Web sites that include detailed information on HIPAA and related healthcare issues.

Provider Forms

Downloads & Links

• Adjustment Request Form
• Vālenz Portal

General Forms

Downloads & Links

• Adjustment Request Form
• Credentialing Criteria

  Find out more about how to become an in-network provider with PHP, including information about what to expect during our credentialing process, recredentialing, and more.

• Healthcare Organizational Facility Credentialing Form
• InstaMed Network Funding Agreement
• PHP Provider Change Form
• Provider Participation Request Form
• Vālenz Portal

Pharmacy Forms

Downloads & Links

• ESI Mail Order Fax Form (For Doctors)
• ESI Mail Order Member Enrollment Form
• Pharmacy Prior Authorization Request Form
• Request for Adding Drug to Formulary

Medical Management Forms

Downloads & Links

• Applied Behavior Analysis - Autism Initial Assessment
• Applied Behavior Analysis Treatment
• Optum Transplant Referral Form
• Prior Authorization Form
• Referral to Out-of-Network Provider Form
• Sleep Study Request Form