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Member Forms

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Enrollment application form. This PDF form allows you to type directly onto it before printing. All other forms (below) must be printed first and then hand written.Johns Hopkins US Family Health Plan application form
Allotment Authorization formDownload the Allotment form
Automatic Payment formDownload the Auto Pay form

Johns Hopkins US Family Health Plan Authorization for use and disclosure of Protected Health Information (PHI).

 

USFHP Authorization Explanation Letter

Authorization for Release of Health Information - Standing

Authorization for Release of Health Information - Unique

Representation for Legal Responsibility for a Minor Child

If you are ever required to pay a provider use this form, along with a copy of your receipt for full reimbursement. PLEASE NOTE: For Pharmacy reimbursement claims, please use form below.Johns Hopkins US Family Health Plan Reimbursement Form
Pharmacy: Home delivery is available for up to a 90-day supply of approved medications through Rite Aid at Wyman Park. Home delivery is best suited for medications you take on a regular basis.Mail order form
Brand-name drugs with a generic equivalent may be dispensed only if your physician submits a medical necessity request  and approval is granted by USFHP.Pharmacy Prior Authorization Form
In the event that you fill a prescription at a non-network pharmacy due to an emergent situation, you may seek reimbursement for incurred cost

Prescription reimbursement claim form

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