Get Phip Enrollment Request Form - Pers Health Insurance Program

This guide provides comprehensive instructions on completing the PHIP Enrollment Request Form for the PERS Health Insurance Program online. It outlines each section of the form, ensuring you can navigate through the required information efficiently.

Follow the steps to complete your enrollment accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in your requested enrollment date. This is the start date for your PHIP coverage. Be aware that during peak enrollment periods, there may be delays in processing.
3. Provide the required retiree information. Ensure all details are accurate to prevent processing issues.
4. List all family members you wish to enroll, ensuring you include any dependents already enrolled. Documentation such as birth certificates or adoption notices for dependents under 26 is needed.
5. Complete the reason for your enrollment. If 'Group Coverage Ending' is selected, include proof of your current coverage.
6. If changing your medical plan, ensure you have also completed a termination form.
7. Fill out the Medicare information for each enrolling member that is Medicare eligible, attaching copies of their Medicare cards.
8. Check the box for your selected medical plan. Remember that switching from Select Value to Core Value plans is not allowed after enrollment.
9. Determine if you want to enroll in dental coverage and select one dental plan for all members.
10. Choose your payment options. If pension deduction is selected, ensure the pension holder's signature is included, or attach a voided check for electronic funds transfer.
11. Answer the important questions on page 3 for every enrolling member.
12. Read and acknowledge the release of information, lock-in, and agreement sections on pages 3 and 4.
13. Sign and date the form. Ensure that the requested enrollment date is after the signature date, which cannot be earlier than 90 days prior.
14. If completing the authorization to disclose protected health information, fill out page 5.
15. Keep the yellow copy for your records, then mail the white copy and any required attachments to the PERS Health Insurance Program at the provided address.

Start filling out your PHIP Enrollment Request Form online today to ensure you have the health coverage you need.