Forms

Physicians Health Plan has all of our Provider forms easily accessible at a click of a button. Please choose the form from the list below that best fits your needs.

Appeals

Provider Appeal Form

Claims

Claim Adjustment Request Form
Claim Inquiry Form
Medical Records Submission form

Credentialing

HAAP Ancillary Provider Application
MMUC Initial Application

MyPHP Web Portal

MyPHP Access Termination Form

Out-of-Network

Out-of-Network Authorization Request Form

Pharmacy Services

Prescription Drug List
This is the list of covered medications. Please note that if you have a 3-tier plan, all medications listed at the 4th tier would fall under the 3rd tier.
Sparrow Employee Prescription Drug List
If you are a Sparrow Caregiver (employee) and are in group 1269, then this prescription drug list is applicable to you.

Prior Authorization Forms

Authorization-Notification Table
DME Authorization Request Form
Home Health Care Request Form
Medication Prior Authorization Form
Outpatient Rehab Therapy Request Form
Prior Authorization Request Form for Services
Bariatric Surgery Request Form

Provider Updates

Provider Demographic Update Form

Specialty Medication

CVS/Caremark Specialty Pharmacy Form
Coram/CVS Home Infusion Referral Form
Walgreens Home Infusion Services Referral Form
Walgreens Specialty Pharmacy Request Form