Forms
- Already have trusted Providers? Nominate them to join the Prime Healthcare Network.
Please complete and return the Nomination Form. Email it to EHPprovidercontracts@primehealthcare.com or fax it to 909-235-4405.
Other Health Coverage – Coordination of Benefits information
Medical Declination and Waiver Form
Have another medical coverage and would like to waive medical benefits?
If Members or Providers disagree with benefit decisions, they may appeal or dispute using the forms below:
- Member Appeal Request – download fillable Microsoft Word form
- HIPAA Authorize for disclosing the information form
- Referral/Authorization form
- Approval for a Sleep Study OSA Form
Overage Disabled Verification Form
Continuation of Care – New Employee
New to Medical Plan and need assistance for continuing with a Provider that you were established with, have your provider fill this form to check if you would qualify for a Continuation of Care