Prescription Drug Reimbursement Form
Use the Prescription Drug Reimbursement Form to file an eligible prescription drug claim reimbursement. See form for instructions.
Prescription Drug Reimbursement Form (PDF)
Member Record Request Form
Use this form to request your member record
Member Record Request Form (PDF)
Member Reimbursement Claim Form
Use the Member Reimbursement Claim form to file an eligible medical claim reimbursement. See form for details and instructions.
Member Reimbursement Claim Form (PDF)
File an eligible behavioral health claim reimbursement. See form for details and instructions.
Member Behavioral Health Reimbursement Claim Form (PDF)
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.
NHP Bike Helmet Reimbursement Form (PDF)
Fitness Reimbursement Form
Get fit, get paid. The NHP fitness benefit varies by plan. An eligible individual must be enrolled in both NHP and a qualified gym/health club for at least 4 months in the current calendar year to be eligible for the fitness benefit. The easiest way to request your fitness program reimbursement is on our secure member portal mynhp.org. You can also download a printable fitness reimbursement form by clicking on your plan name below.
NHP Prime (including Health Connector) and Prime Solutions plans (PDF)
NHP Weight Loss Program Benefit Coverage Request Form
Most NHP Prime 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. Check your Schedule of Benefits on mynhp.org to determine if your plan includes the weight loss benefit. Please note, this benefit does not cover food, nutritional supplements, or enrollment/registration fees.
NHP Weight Loss Program Benefit Coverage Request Form (PDF)
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.
Childbirth Education Reimbursement Form (PDF)
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.
Breastfeeding Support Form (PDF)
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.
Continuity of Care at Cancer and Pediatric Facilities Notification Form
NHP members newly enrolled through a small employer group who began an active course of treatment for a serious illness prior to enrolling in NHP’s Easy Tier Hospital Network plan may be eligible to continue treatment at the lowest member cost-sharing tier (Tier 1). Click here to determine if you are eligible. If eligible, please submit the Continuity of Care at Cancer and Pediatric Facilities Notification Form prior to the start of treatment in the tiered network plan.