Notice: We are aware of a nationwide cyber security incident impacting Change HealthCare. This does not impact your coverage but may cause delays in claims processing. Change Healthcare, which is owned by UnitedHealth Group, reported on April 23, 2024, that patient/member data may have been compromised, however, the extent of the data breach is not yet known. UnitedHealth has set up a website and toll-free number for members to call for more information. Please visit changecybersupport.com or call 1-866-262-5342 for more information and details on resources available. We continue to closely monitor the situation and will communicate updates as they become available. Our PHP portals are not impacted by this incident.

PHP Pharmacy Form - Member

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Patient Information

Today's Date
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Member Name:
PHP Subscriber Number:
*
Date of Birth
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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
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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

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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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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