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: