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)

Patient Information

*First name: « Required
*Last name: « Required
* Date of birth (mm/dd/yyyy): « Required
*ID number: « Required

*Reference number: « Required

Services denied:

Add another patient

Requesting physician information

*First name: « Required
*Last name: « Required
*Phone number: « Required
Fax number:
*Specialty: « Required

Inpatient Information (if applicable)

Name of facility:
Phone number:

To ensure your privacy, all information will be sent via a secure connection. AmeriHealth will not disclose any personal information to outside persons or entities unless we have written consent or unless authorized by law.

Please see our Notice of Privacy Practices for more information.

Peer-to-peer request form

Contact information

Patient Information

Requesting physician information

Inpatient Information (if applicable)