Nominate a Provider Form
Self-Pay Medical Claim Form
File an Appeal Form
Authorized Representative Form
Records Release Consent Form
Medical Preauthorization Forms
Release Health Information Form
COVID Test Reimbursement Form
Wellness Rebate Forms
Other rebates you may be eligible to earn:
- Diabetes Management ($100) - If you have been diagnosed with diabetes.
- Tobacco Cessation ($50) - If you currently use tobacco or have used tobacco within the past 6 months.
- PEHP WeeCare Rebate ($50) - If you are an expectant mother.
FLEX and HRA Forms
FLEX Claim Form - No Grace Period