Find a Form

Authorized Representative Form

Member Appeal Filing Form

Nominate a Provider Form

Records Release Consent Form

Release Health Information Form

Self-Pay Claim Form

Direct Primary Care Subscription Reimbursement Form

Direct Primary Care Opt-Out 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)

Term Life Change Form

Vision Coverage Termination Form

Note: Pharmacy benefits don't apply to some school districts. Check with your employer.

Express Scripts Home Delivery Order Form

Coordination of Benefits/Direct Claim Form

Pharmacy Preauthorization Forms

Submit Direct Claim Form Electronically

Rx DirectPay Program Form

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 Claim Form - No Grace Period

FLEX Claim Form - Jordan School District / Sept groups