Forms + Downloads

General Forms

• Adjustment Request Form
• Credentialing Criteria

  Find out more about how to become an in-network provider with PHP, including information about what to expect during our credentialing process, recredentialing, and more.

• Healthcare Organizational Facility Credentialing Form
• InstaMed Network Funding Agreement
• PHP Provider Change Form
• Provider Participation Request Form
• Vālenz Portal

Pharmacy Forms

• ESI Mail Order Fax Form (For Doctors)
• ESI Mail Order Member Enrollment Form
• Pharmacy Prior Authorization Request Form
• Request for Adding Drug to Formulary

Medical Management Forms

• Applied Behavior Analysis - Autism Initial Assessment
• Applied Behavior Analysis Treatment
• Optum Transplant Referral Form
• Prior Authorization Form
• Referral to Out-of-Network Provider Form
• Sleep Study Request Form