Please use the Enrollment Form for employees enrolling for any reason. The Change Form is used for any change to a subscriber's or a dependent's existing coverage.

Please feel free to contact your producer or the PHP Sales Department if you have questions.

HMO Forms

Group Policy Application

Enrollment Form

Change Form

Authorization for Use and Disclosure of Protected Health Information

Designation of Personal Representative

Certificate of Creditable Coverage- Medicare Part D

The forms below are for our medically underwritten plans only.  Please contact your account manager if you have questions.

PPO Forms

Enrollment Form

Medical Questionnaire

Employer Application 2-50

Employer Application 51+

Change Form