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PHP Pharmacy Form - Member

Fields marked with a red arrow are required fields.
  

Patient Information

Today's Date
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*
Member Name:
PHP Subscriber Number:
*
Date of Birth
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What is the Best Way to Contact You?


*
Contact Phone Number
Contact Email Address
Mailing/Street Address

Prescriber Information

Provider Name
Provider Office Phone Number:

Medication Information

Medication
Dose:
Frequency:
If this is a continuation of therapy, how long have you been on the medication?
Additional Information
Please upload all relevant files.
(Allowed extensions: *.jpeg, *.jpg, *.pdf, *.png)
Security Code
Type Security Code

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

NCQA Accreditation Seal
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

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