Orchard - Unchanged

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General Forms

Authorized Representative Form PDF file

Member Appeal Filing Form PDF file

Medical Preauthorization Forms

Nominate a Provider Form PDF file

Records Release Consent Form PDF file

Release Health Information Form PDF file

Self-Pay Dental and Medical Claim Form PDF file

Duplicate Coverage Disclosure for Coordination of Benefits Form PDF file (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 PDF file

Coordination of Benefits/Direct Claim Form PDF file

Pharmacy Preauthorization Forms

Submit Direct Claim Form Electronically

Rx DirectPay Program Form PDF file

Wellness Rebate Forms

First Steps ($50) Rebate PDF file

Next Steps ($50) Rebate PDF file

Other rebates you may be eligible to earn:

FLEX and HRA Forms

FLEX Claim Form - No Grace Period PDF file