Forms & Resources
Refer to your member handbook to understand the best way to take advantage of the services and benefits of Johns Hopkins USFHP.
Outpatient Referral Guide
These guidelines explain to providers the referral and pre-authorization status of outpatient services. You can refer to it for a basic understanding of what to expect when you receive certain outpatient services.
Authorization for Release of Health Information—Standing:
This form lets you choose someone you trust to have access to your health records. You can also decide how much of your personal health information you want that person to know. Don’t worry, if you don’t fill out this form, Johns Hopkins USFHP will continue to keep your health information protected and private.
Authorization for Release of Health Information—Specific Request:
Like the “standing” version of this form, you can choose someone you trust to have “one-time” access to a specific part of your personal health information. Don’t worry, if you don’t fill out this form, Johns Hopkins USFHP will continue to keep your health information protected and private.
Compound Drug Prior Authorization Form:
Compound Drug Prior Authorization Form is utilized to request prior authorization for a compounded drug that rejects at the pharmacy.
Enrollment Fee Allotment Authorization:
Fill out this form if you would like to authorize allotment to be taken from your military retirement pay in order to cover the yearly USFHP enrollment fee.
Enrollment Fee Automatic Payment:
This form allows you to authorize automatic checking account withdrawal, or monthly or quarterly credit card charges to pay your yearly USFHP premium.
Pharmacy Home Delivery:
Fill out this form if you would like to have your prescriptions mailed to your home. Home delivery is available for up to a 90-day supply of approved medications through Walgreens Pharmacy on Remington. Home delivery is best suited for medications you take on a regular basis.
Out of State Pharmacy Home Delivery:
Fill out this form if you live outside of Maryland and would like to have your prescriptions mailed to your home. Home delivery is available for up to a 90-day supply of approved medications through AllianceRx Walgreens Prime Pharmacy. Home delivery is best suited for medications you take on a regular basis.
Pharmacy Prescription Reimbursement Claim 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.
Pharmacy Prior Authorization:
In order to ensure certain prescribed medications will be covered by (i.e. brand-name drugs with generic equivalents; drugs not listed in the formulary; drugs that require prior authorization, step therapy, or medical necessity), your doctor must request and receive approval from our plan.
Representation for Legal Responsibility of a Minor Child:
If you are over 18 years old, filling out this form will give you the right to represent and make health care information-related decisions about a minor child who is 17 years old or younger. The adult representative can only be the minor’s parent, step-parent, legal guardian, or kinship caregiver.
If you are ever required to pay a provider, you can submit this form, along with a copy of your receipt, for full reimbursement. Note: for pharmacy/prescription reimbursement claims, please use the pharmacy prescription reimbursement claim form.
Other Health Insurance (OHI) Form
USFHP members are required to submit information about other health insurance policies by which they are covered. If you have not reported this already, please complete and mail this form to us. Call 1-800-808-7347 if you have any questions.