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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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© 2024 Physicians Health Plan
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

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