Forms

In order to enroll in PHIP or make a change to your account you must submit the applicable form to PHIP within the time frames allowed. You can mail, email or fax the form. The effective date for any event or update will either be the first of the month of the event, if submitting in advance of the event, or the first of the month after your completed form has been received by PHIP.

PHIP Enrollment Request Form

Submit a PHIP Enrollment Request Form when initially enrolling into PHIP, adding a dependent or making a change to your PHIP coverage either at plan change or due a family status change. If you are changing your PHIP coverage, a PHIP Disenrollment Form must also be submitted in order to term the original plan(s).

PHIP Address Change Form

If you change your address, you must notify PHIP in writing. Complete, sign, date and submit a Change of Address Form to PHIP. Address changes may be sent via mail or fax. Email requests will not be accepted.

PHIP will notify the appropriate health plan.

If you do not notify PHIP within 30 days of moving outside a service area, you may lose coverage. You must maintain a permanent residence within the United States to be eligible for PHIP. If you reside in another country, you are not eligible to keep PHIP coverage.

PHIP Disenrollment Form

If you would like to end your PHIP coverage, you will need to complete and send a PHIP Disenrollment Form. This change will be effective on the first of the month after we receive your PHIP Disenrollment Form, unless you request a later date. If your spouse and/or dependent child (over 18) are part of your plan, they will also need to sign the form.
If anyone in your family stops their dental coverage, the whole family will lose their dental coverage.

PHIP Authorization to Disclose Form

If you would like to authorize an individual to contact PHIP and obtain eligibility or enrollment information about your PHIP account, you must submit a PHIP Authorization Form for each individual that you are authorizing. The authorization is good for 24 months and must be updated after 24 months. This form does not give authorization to make any changes to the member’s account. A Power of Attorney would be required in that instance.

PHIP Payment Option Form

Any time that you want to change the method of payment on your PHIP account you would submit a PHIP Payment Option Form. The change will be effective on the next billing cycle.