Public Employees Retirement System

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 form has been received by PHIP.

PHIP Enrollment Request Form

The Enrollment Request Form would be submitted if you are 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

In the case of an address change, you will want to submit a PHIP Address Change Form. The change will be effective the first of the month after the Address Change Form is received by PHIP, unless you state a future effective date. If your new residential address is outside of the service area of your current health plan, you must submit a new PHIP Enrollment Request Form and a PHIP Disenrollment Form in order to be enrolled in health coverage available within your new service area.

PHIP Disenrollment Form

If you are terminating your coverage with PHIP or dropping dental from your PHIP coverage, you must submit this form. The termination will be effective the first of the month after PHIP receives this form, or upon a future effective date as documented on the form. You must submit a PHIP Disenrollment Form in conjunction with a change to coverage during plan change so that the original coverage is terminated at the same time the new coverage becomes effective.

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 Options Form

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

Do you have the correct Enrollment Request Form?

If you are enrolling effective January 1, 2018 or later; or are making a change due to Plan Change – Use the 2018 PHIP Enrollment Request Form .

Using the wrong form can delay your enrollment or may cause you to miss the enrollment opportunity all together.

Still having trouble determining which Enrollment Request Form to use? Call PHIP at (800) 768-7377 for assistance.