For on-exchange policies, please visit your carrier's website:
For off-exchange policies, please view your carrier's application agreement below:
Physicians Health Plan Application Agreement
PEDIATRIC DENTAL COVERAGE ATTESTATION – REQUIRED TO PURCHASE THIS POLICY
The PHP health benefit plans do not include pediatric dental coverage. If you want to cover a child under your plan, federal and state laws require you to purchase pediatric dental coverage offered by an Exchange-certified standalone dental plan to be eligible to purchase one of PHP’s health benefit plans.
PHP is required to obtain reasonable assurances from you that you have such coverage before PHP is permitted to sell you this health benefit plan. Therefore, please attest to the following:
I understand that I am only eligible to purchase this PHP health benefit plan if I also purchase pediatric dental coverage offered by an Exchange-certified standalone dental plan.
I certify that I have purchased pediatric dental coverage offered by an Exchange-certified standalone dental plan.
I will inform PHP immediately if this pediatric dental coverage is discontinued for any reason.
I understand that if I am not truthful in this attestation, the PHP health benefit plan may be rescinded by PHP due to fraud or intentional misrepresentation of material fact, and that you may be required to reimburse PHP for any medical expenses that PHP paid on your (or your dependents) behalf.
AUTHORIZATION AND SIGNATURE
I understand and agree that coverage, if approved, will begin as specified above.
I understand that coverage will be provided under an individual contract. I understand that PHP does not issue individual coverage through any arrangement with an employer. PHP is not responsible for any action taken by an employer that results in this coverage being considered group coverage under state or federal law. The employer is solely responsible for any such finding.
I agree that if I am enrolling in a product that features certain designated providers, PHP may share my name, address and telephone numbers, as well as my past, current and future health and account records with such designated providers about service I have received from such designated providers and other care providers unrelated to such designated providers. These records may be used by the designated providers as needed to manage or coordinate my care and to improve the quality of that care.
PHP primarily relies upon the information provided and full disclosure of the information listed on this enrollment form in the decision whether to accept the Applicant and/or dependent(s) listed on this enrollment form for coverage. I acknowledge the importance of providing accurate and complete information. I acknowledge I must answer all questions in the enrollment form, even if the Applicant, and/or dependent(s) listed on this enrollment form, currently have coverage or had prior coverage with PHP.
I understand and agree that payment of a claim does not preclude the right of PHP to deny future claims or take any action it determines appropriate, including cancellation of the policy and seeking payment of claims already paid.
I agree to notify PHP immediately of any change in my, or my dependent(s), enrollment information between the date of this enrollment form and the effective date of coverage. Failure to notify PHP of any change in the information contained on this enrollment form may result in the denial of a claim, cancellation of the policy, or a premium adjustment.
Upon request, I agree to furnish additional information needed concerning eligibility of myself and/or any dependent(s) enrolling for coverage.
I have read the preceding instructions, statements and answers and represent them to be true and complete to the best of my knowledge and belief. I understand and agree PHP will act in reliance upon the information I have provided in this enrollment form, which materially affect enrollment eligibility may result in the denial of a claim(s), cancellation of the policy, or a premium adjustment.