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PHP Pharmacy Form - Provider

Fields marked with a red arrow are required fields.
  

Patient Information

Today's Date
RadDatePicker
Open the calendar popup.
*
Patient Name:
PHP Subscriber Number:
*
Date of Birth
RadDatePicker
Open the calendar popup.
Weight
*
Patient Phone Number
Address

Prescriber Information

*
Provider Name
Provider NPI Number:
*
Office Phone Number:
Office Fax Number:
Office Contact Name:

Medication Information

Medication:
Dose:
Frequency:
Diagnosis & ICD Code:
If this is a continuation of therapy, how long has patient been on the medication?

If medication is an infusion medication, please also complete the following:

HCPCS Code
This Medication Will Be Given:
Hospital/Facility Name:
Facility NPI Number:

Previous Therapies Attempted

Previous Therapy Number One

Name of Therapy Attempted:
Dose/Frequency:
Start Date
RadDatePicker
Open the calendar popup.
Stop Date:
RadDatePicker
Open the calendar popup.
Reason for Discontinuation:

Previous Therapy Number Two

Therapy Attempted:
Dose/Frequency
Start Date
RadDatePicker
Open the calendar popup.
Stop Date:
RadDatePicker
Open the calendar popup.
Reason for Discontinuation:

Additional Information

Please Add Any Additional Information:
Please Upload Any Applicable Documents:
(Allowed extensions: *.jpeg, *.jpg, *.pdf, *.png)
Security Code
Type Security Code

SUBMIT

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1301 N. Hagadorn Rd., Suite 1E
East Lansing, MI 48823
517.364.8400 or 800.562.6197

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Physicians Health Plan (PHP) is NCQA Accredited for its Commercial HMO/POS combined product and Health Insurance Marketplace product.
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© 2014 Physicians Health Plan Pencil
1400 East Michigan Avenue
Lansing, MI 48912
517.364.8400 or 800.562.6197

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Physicians Health Plan (PHP) is URAC Accredited for its HMO, Plus and Health Insurance Marketplace products. CAQH Core Seal