Provider peer-to-peer request form

If this is an urgent request, please call the AmeriHealth Medical Director’s Office at 215-241-0494. For all out-of-area requests, please call 1-888-814-2244. All non-urgent calls will be returned within 24 hours.

Please complete all information requested on this form.

(* required fields)

Contact information

Patient information

Requesting physician information

Inpatient information (if applicable)