Prescription Drug Reimbursement Form
If you have paid for a covered prescription from a pharmacy who does not participate with NHP, use the Prescription Drug Reimbursement Form to file a claim for reimbursement.
Member Reimbursement Claim Form
If you have paid for a covered service from provider who does not participate with NHP, use this form to file a claim for reimbursement.
Bike Helmet Reimbursement Form
When you buy safety helmets for toddlers, children and adults, NHP will reimburse 50% of the purchase price of one new helmet, per member, per calendar year up to a $15.00 reimbursement.
Fitness Reimbursement Form
Get fit, get paid. Our Fitness benefit will reimburse members in qualifying NHP plans up to $150 per year toward their fitness program memberships at qualifying health clubs. And under some NHP plans, another $150 in fitness program reimbursement is available for covered family members. To qualify, you must belong to a health club and have been a NHP member for a full four months in a calendar year.
NHP Weight Loss Program Benefit Coverage Request Form
Most NHP plans come with a Weight Loss Benefit that rewards members or someone in their family for losing weight the healthy way. Our Weight Loss Benefit offers a little extra motivation—and money—when a qualified member joins Weight Watchers or Jenny Craig for six months or longer. Please note, this benefit does not cover food, nutritional supplements, or enrollment/registration fees.
Childbirth Education Reimbursement Form
Childbirth education classes, plus parenting and infant CPR classes, are available to you and your partner or support person free of charge at many primary care sites and hospitals.
Speak to the provider caring for you during your pregnancy or the facility where you plan to deliver about enrolling. If they do not offer a childbirth education program, NHP will reimburse you for the cost of these classes up to $130 per pregnancy. You can combine multiple classes up to the $130 limit per pregnancy. A Childbirth Education Form must be submitted to obtain the reimbursement.
Breastfeeding Support Form
Breastfeeding support classes are also available free of charge at many primary care sites and hospitals. These classes are a support group for pregnant women, and they provide information about the benefits of breastfeeding, along with helpful tips, resources, and ways to manage common breastfeeding challenges.
Speak to the provider caring for you during your pregnancy or the facility where you plan to deliver about enrolling. If they do not offer a breastfeeding support program, NHP will reimburse you for the full cost of these classes. A Breastfeeding Support Form must be submitted to obtain the reimbursement.
Download the Breastfeeding Support form.
Personal Representative Designation Form
You have the right to choose one or more persons to act on your behalf with respect to the protected health information that pertains to you. If you would like to exercise this right, please complete and return this form to us.