Transcription of PHIP Enrollment Request Form - pershealth.com
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PHIP Enrollment Request Form - pershealth.com
37783050 (9/18)PHIP Enrollment Request FormPlease contact PHIP if you need information in another language or format (Braille)EnrollmentOAR 459-035-0070A completed PHIP Enrollment Request Form must be submitted when you are initially enrolling, adding a dependent or making a change to your PHIP coverage either at plan change or due to a family status change. Signature is required by all enrollees over the age of Enrollment Request FormOAR 459-035-0080In order to avoid a gap in coverage or forfeiting your Enrollment opportunity, please submit all requested information/documentation with the completed Enrollment Request Form prior to your requested effective date.
377835 9/18. Section C . Choose Your Non-Medicare Plan (If applicable) Non-Medicare family members must enroll under the same health plan Individuals enrolling in a PHIP Non-Medicare Plan
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