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.

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