PEHP Fia Care Opt-in

Primary Care Services

Designation Form
Fia Care offers primary care services for your healthcare needs, including annual physicals, treatment for minor illnesses and injuries, and disease management assessments and evaluations. For a comprehensive list of services, visit fia.care.
I have a PEHP Traditional Plan and am signing up for Fia Care servicesI have a PEHP High Deductible Plan and would like to use Fia Care services. I will be responsible for paying the fee for service costs until I meet my deductible. (see https://fia.care/pehp-individual-enrollment/ for pricing)I have a PEHP High Deductible Plan and would like to use Fia Care services and pay the monthly subscription fee until i meet my deductible. (see https://fia.care/pehp-individual-enrollment/ for pricing)
SelfSelf and all my Covered Dependents (all covered dependents will be added with this option)
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
MaleFemaleOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PEHP Member ID
Please take a picture of your PEHP ID card and submit with this form

Cancelof

Please enter information for all covered dependents, click on the +add row button to enter additional dependents*

Primary Care Services