California PHP

Enrolling in PHP (HMO SNP) is easy. If you would like to enroll in the plan, you can:

• Fill out a digital enrollment application here.
  
  
• Contact Member Services by phone or email.
  
  
• Download the enrollment application forms listed below, complete them and fax or email them to us. Our fax number is (888) 235-8552.
  
  
  • Individual Enrollment Request – This is the application form to enroll into PHP.
  • Enrollee Demographic Information – This form asks you to identify your gender, race, and language preferences.
  • Statement of Understanding – This form details some of the important terms of enrollment into and membership in the plan.
  • Authorization for PHP to Request My Health Information – This form is used by the plan to request health information related to your HIV status from your primary care doctor to verify eligibility for the plan.
  • Authorization for Use or Disclosure of Health Information – This form allows the plan to request your health information from your doctors. This form is primarily used to allow your Registered Nurse Care Manager to obtain your records to create and update your treatment plan.
  • Disability and Health Information Questionnaire – This form ask you how and when you became disabled and for what health conditions you are being treated. This information is for your Registered Nurse Care manager so he or she can better assess you immediate health needs.
  • New Enrollee Non-Plan Provider Transition Policy – This form asks you to identify any providers you are currently seeing for treatment who are not in PHP’s provider network.
  • Request and Authorization for Email Communication – Complete this form if you would like the plan to communicate with you via email.
  • Health and Wellness Benefit Option Election – Use this form to choose which Health and Wellness Benefit option you want, i.e., a gym membership or over-the-counter (non-prescription drug coverage) pharmacy items.
  • Health Risk Assessment – The information you provide to us on this form helps us develop a care plan with your primary care provider (PCP) and any specialists you may be seeing and helps ensure your enrollment into PHP is easy as possible.

If you prefer, you can download a “zip” file containing all of the above forms.

If you have any questions about the plan, please feel free to call us or email us.

You will need the Adobe Acrobat Reader program to view the above forms. To download this free program click here or use the link above – the link will open a new window and take you to the Adobe website.

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