FORMS and DOCUMENTS
Enrollment form and instructions
Welcome to US Family Health Plan. To enroll, just download and complete this enrollment form. Instructions are also included for your convenience.
Primary care physician (PCP) change form
Use this form to change your PCP. Complete the form and mail it to:
Attn: Member Services
US Family Health Plan
P.O. Box 169001
Irving, TX 75016
Note: The change forms are pages 8 through 10 of the enrollment form though you only need to complete these three pages to change your PCP.
This handbook provides you with an explanation of the key features of the US Family Health Plan. It is presented in simplified terms and cannot cover all details of the plan. The administration of the plan is subject to the actual terms and provisions of the plan as set forth in the formal plan document.
In the event of a discrepancy between the formal plan document and the summary outlined in this booklet, the formal plan document will take precedence. A quick reference summary of benefits begins on page 10 for easy review, and a glossary of terms and definitions begins on page 31. Please read this handbook carefully and keep it for future reference.
This form can be used to pay your US Family Health Plan enrollment fee using your monthly allotment.
Child well-care and immunization recommendations
This document provides you with information about child well-care exams and recommended immunizations for children age 7 through 18.
US Family Health Plan Privacy Notice
You may download a copy of the US Family Health Plan Privacy Notice at any time. Periodically, a copy is mailed to you. However, a current copy of the notice is always posted here.
Download Notice (1.8M PDF)
TRICARE Young Adult (TYA) enrollment application
Use this form only for enrollment in the TRICARE Young Adult program.
Requests for reimbursements must be received within one year of the date of service. Any requests that are submitted after one year will be denied for failure to file in a timely manner.
Pharmacy reimbursement form
The pharmacy reimbursement form is used on those occasions when you are not able to fill an urgent prescription at a network pharmacy. On those unique occasions, you will need to complete this form to apply for reimbursement. For example, if you are vacationing in Colorado and become ill and must fill your prescription at a pharmacy that is not affiliated with CVS or Maxor, you would complete this form and send it to US Family Health Plan to be reimbursed for the out-of-pocket expense.
Pharmacy Reimbursement Request (44KB PDF)
New patient questionnaire for Maxor Pharmacy
Please fill out this form to ensure we have your current contact information and known allergies.
Download Form (Pharmacy – 1.3M PDF)
Mail order form
Maxor Pharmacy’s Front Door Service mails your prescriptions right to your home! You get a 90-day supply for the same copay as a 30-day supply plus free postage and handling. It’s easy to sign up. Just download this form and submit to Maxor Pharmacy.
These forms and documents are provided to you as a convenience and imply no legal consultation or advice on behalf of US Family Health Plan.
TX Statutory Durable Power of Attorney
This is the form promulgated by the Texas Legislature for designating an agent empowered to take certain actions regarding your property and finances. The statutory basis of this form is Texas Probate Code §490.
TX Statutory Advance Medical Directive
This is the form promulgated by the Texas Legislature for indicating your wishes in the event you are diagnosed with a terminal or irreversible condition. The statutory basis of this form is Texas Health and Safety Code §166.033.
Texas Out-of-Hospital Do Not Resuscitate
The Out-of-Hospital Do-Not-Resuscitate form allows you to Instruct EMS (ambulance) staff that you do not want to be resuscitated if you stop breathing and your heart stops beating. In an emergency, EMS staff do not have access to or information about your Advance Medical Directive or your medical decision-maker. They are required to start life-saving measures unless they can immediately determine this is not what you want.
Texas Residents: This form allows you to declare that you do not want certain resuscitative measures used on you if there are EMS staff taking care of you. Recent changes in the Texas law also authorize EMS to look for an ID band to alert EMS staff to your out-of-hospital DNR wishes. For more information about this form, including where you can purchase an ID bracelet, visit: http://www.dshs.state.tx.us/emstraumasystems/dnr.shtm.
Louisiana Residents: If you are a resident of Louisiana and wish to have this form in place, please talk with your primary care physician. Your physician must sign your out-of-hospital do-not-resuscitate order if you want one.
Notification of Appointment of Personal Representative