Get Phcs Network Authorization Form - Geisinger Health Plan

Completing the PHCS Network Authorization Form is an essential step for employees whose dependents reside outside the EMHS service area. This guide will provide you with clear, step-by-step instructions to effectively fill out the form online.

Follow the steps to complete the PHCS Network Authorization Form online.

1. Click ‘Get Form’ button to access the form and open it for editing.
2. In the form, begin by entering your employee name in the designated field. Ensure that the name matches your official records.
3. Next, provide your Geisinger Member ID number if it is available. This helps to identify your account more efficiently.
4. Fill in your EMHS employee number. This information is crucial for processing your request.
5. Enter your social security number in the specified section for verification purposes.
6. Indicate whether you and your dependents reside outside the EMHS service area by checking the appropriate box.
7. For each dependent, provide their name in the designated fields. Repeat this for all dependents that require coverage.
8. For each dependent listed, include the date they began living or attending college outside the EMHS service area, using the MM/DD/YYYY format.
9. Once all information is filled out, affix your signature at the bottom of the form. This signifies your agreement to the contents provided.
10. Finally, indicate the date of signing and ensure all required fields are complete before submitting the form online.
11. Save your changes, download the completed form, or print it for your records. You can also share it as needed.

Complete the PHCS Network Authorization Form online today to ensure your dependents receive the necessary healthcare coverage.