EHP has many forms available to you for your convenience. Look below for one that best fits your needs.
EHP Health Visit Report Form
Please complete this form if you received a letter from EHP saying to do so in order to qualify for the voluntary Healthy Choice Rebate Program. This form is to be completed by a licensed health professional (MD, DO, NP, PA).
Mutual Health Services Claim Form
In some circumstances, you may be required to pay upfront for medical services. For example, if you are traveling outside the country, you may be required to pay for medical services with a credit card or cash. If you should pay upfront for a medical service, a manual claim form can be submitted to Mutual Health Services along with the invoice from the provider of service.
Coordination of Benefits (COB)
Coordination of Benefits (COB) is the procedure used to pay healthcare expenses when you or an eligible dependent is covered by more than one health plan. The COB procedure follows the rules established by the laws of the state of Ohio.
Authorization to Disclose Protected Health Information
To enable spouse, domestic partner, child, power of attorney, guardian, or other person to receive protected health information from EHP related to health plan programs or services.
Medical Management Prior Authorization Form
For health care provider to submit for health plan programs or services needing prior approval (click here for form).
Cleveland Clinic Pharmacies Home Delivery
For your convenience, EHP also offers a home delivery service through the Cleveland Clinic Home Delivery Pharmacy. To get started, please visit the Cleveland Clinic Home Delivery Pharmacy MyRefills website where you can set up your account, change your billing information and shipping address, or check on the status of your order. Please call 216.448.4200 for questions or additional information on the Cleveland Clinic Home Delivery Pharmacy.
Cleveland Clinic EHP Appeal Form
Appeals form or EHP pharmacy or medical appeals. This form is not for EHP Healthy Choice program appeals.
Pharmacy Prior Authorization/Formulary Exception
Prior authorization is necessary for coverage of certain medications. These medications are listed in the Cleveland Clinic EHP Drug Formulary Book that was inserted in the Cleveland Clinic Summary Plan Description (SPD). The medications on the list may change during the year due to new drugs being approved by the FDA or new indications are established for previously approved drugs. A Prior Authorization/Formulary Exception Form must be completed or sufficient documentation must be submitted before a case will be reviewed.
Disclaimer: All requests must meet the clinical criteria approved by the Pharmacy and Therapeutics (P&T) Committee before approval is granted. In some cases, approvals will be given a limited authorization date. If a limited authorization is given both the member and the physician will receive documentation on when this authorization will expire. Most requests will be processed within 1-2 business days from the time of receipt. A response will be faxed to the requesting physician, and the member will be informed of the request and the decision via mail.