Find a Form

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

Direct Primary Care Subscription Reimbursement 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

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

Medicare Supplement Forms

Medicare Supplement Enrollment Form