Physicians Partners Health Plan

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1 Nov.
PPHP Launches New Web Site To Better Serve Needs of Clients

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Review complete online overview of HIPAA and the new regulations.

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GROUP PRESCREEN:

Fax Back to: Physician Partners Health Plan
Representative Name: James Schieferle
Facsimile: (479) 444-6031
Phone Numbers: (888) 877-PPHP (Toll Free)
(479) 444-PPHP

Please complete this Pre-Screen Worksheet, or Download a printable version now. PPHP will then review the information supplied and will fax back our proposed health plan information.

UNDERWRITING PRE-SCREEN WORKSHEET

GROUP INFORMATION:

Group Name

Address, City & State

Zip

Phone Number(Required)

Nature of Business

List Multiple Locations

Total No. Of Employees At Sites

PLAN INFORMATION
Plan Type Desired	Deductible
Drug Card?	Current Health Carrier
Total Premium	Current Plan Design (HMO, PPO, POS, Traditional)
No. of Employees Applying For Coverage	Renewal Date (mo/dd/yr)
Total No. of COBRA Participants	Employer Contribution:(EE) % (Dep) %)

HEALTH CONDITIONS
Employee, Spouse, or Child Name	Age/Sex	Diagnosis/Medical Condition	Date Onset	Describe Treatment/Meds.	Recovery Date or Ongoing Condition

EMPLOYEE CENSUS
Name	DOB	Gender	Coverage Desired

Should you have more than ten employees, please Download a printable version of this application, fill out the remaining information in the Employee Census table, and fax it to the number listed below. Please include "Employee Census Extension List" at the top of the sheet along with your company name and contact information. Thank you.

Disclaimer: Your estimate based on the information supplied. This pre-screen is not a guarantee of coverage and is not intended to replace the medical underwriting process. Any census change and medical information not disclosed may alter this pre-screen. Please include a copy of this pre-screen with the case submission.

Physician Partners Health Plan
Representative Name: James Schieferle
Phone Numbers: (888) 877- PPHP
(Toll Free) (479) 444-PPHP
Facsimile: (479) 444-6031

Thank you for your time and assistance! Please press the "Submit" button below when finished.