Commonly Used Forms

Commonly Used Member Forms

These forms are in Adobe Acrobat (.pdf) format. Get the Acrobat reader here.

• Member/Subscriber Claim Form (All except Medicare)
• Member/Subscriber Claim Form (Medicare)
• Member/Subscriber General Release of Information Form
• Advance Directives Form
• Injury Questionnaire Form
• Level 1 Appeal Form
• Grievance Form
• Transition of Care Services Form 

Individual Health Plan: Member Plan Change Forms 

• Termination:  When you need to terminate your Individual Plan coverage or a dependant from your plan.
  Individual Plan Voluntary Member Termination Form
   
• Add a Dependant: When you are requesting to add a dependant to your current benefits.
  Individual Plan Member Add Dependent Form and Medical Form 
  

Individual Health Plan: Member Reimbursement Forms  

For Individual PresMetro, PresSolo, and Select members requesting reimbursement for eligible services such as alternate therapies, dental treatment or diagnostic devices, please select the appropriate form below.  For additional information regarding the reimbursement program visit the DontHaveToBeRich website.

• PresSolo Plan: PresSolo Unique Services Reimbursement Form
   
• Select Plan: Select Plan Unique Services Reimbursement Form
   
• PresMetro Plan: PresMetro Unique Services Reimbursement Form

Phone: (505) 923-6980 or 1-800-923-6980 TTY: 1-877-298-7407

Hours:  7:00 a.m. to 6:00 p.m., Monday - Friday

Email: info@phs.org

Mailing Address:  P.O. Box 26267, Albuquerque, NM 87125-6267