Physician Hospital Alliance Forms

2115 Leiter Road, Suite 400

Miamisburg, OH 45432

 

To contact us:

Phone: 937-384-6951

Fax: 937-384-6949

E-mail: Patrick.Kenrick@khnetwork.org

 

 

For New Member Enrollment:

 

Database Information Sheet:

     Page 1

     Page 2

Class A Agreement

2010 New Member Invoice

 

 

For Changes to Referral Info, Practice or Individual Physician:

 

Database Information Sheet:

     Page 1

     Page 2

 

               

For Superior Dental Enrollment, Termination or Changes:

 

A physician in your practice MUST be a current member of PHA to use this service.

 

Enrollment or Change Application

(Please send this form to the PHA at fax 937-384-6949)

 

 

For PHA Health Benefits Enrollment:

 

Participation Agreement

PHA Health Benefits Plan Application and change Form

PHA Employer Medical Questionnaire

 

 

For posting a job opportunity for your practice on the Kettering Medical Center Network website and www.GreaterDaytonWorks.com

 

A physician in your practice MUST be a current member of PHA to use this service.

 

Jobs Online Form