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General Forms

Authorized Representative Form

Member Appeal Filing Form 

Medical Preauthorization Forms

Nominate a Provider Form

Records Release Consent Form

Release Health Information Form 

Self-Pay Dental and Medical Claim Form

Duplicate Coverage Disclosure for Coordination of Benefits Form  (You are obligated to keep PEHP informed of medical/dental coverage that you or an eligible family member have that is not with PEHP.   Use this form to provide this  information and any related changes.  Learn more about “Other Coverage” and “Coordination of Benefits” here)

Pharmacy Forms

Express Scripts Home Delivery Order Form

Coordination of Benefits/Direct Claim Form

Pharmacy Preauthorization Forms

Submit Direct Claim Form Electronically

Rx DirectPay Program Form 

Wellness Rebate Forms

First Steps ($50) Rebate 

Next Steps ($50) Rebate 

Other rebates you may be eligible to earn:

• Diabetes Management  ($100) - If you have been diagnosed with diabetes.
• PEHP WeeCare Rebate  ($50) - If you are an expectant mother.
• Tobacco Cessation  ($50) - If you currently use tobacco or have used tobacco within the past 6 months.

FLEX and HRA Forms

FLEX Claim Form - No Grace Period