Dr. Philip Blair, MD
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For Western Grocers Trust Beneficiaries
Enrollment in Pro Health Advisor Patient Assistance Program
Indicates required field
Date of Birth
Last 4 digits of Social Security *
Needed for Medical records requests.
When is the best day and time to contact you?
What day and time is best for us to work with you on your medical issues?
Are you a member of WGT Health Benefit program?
Please verify that you are an active member of Western Grocers Employee Benefits Trust Medical Benefit plan.
Do you want to enroll in PHA, a patient assistance program for Western Grocers Employee Benefits Trust?
I need more information
We need your approval to enroll in PHA
I will do my best to do the following:
Participate in all parts of Pro Health Advisor's Program
Meet with my Pro Health Advisor each month
Follow the recommendations of my Pro Health Advisor
Follow my food, activity, and lifestyle program with the help of my Pro Health Advisor
Record my food, activity and measurements in my personal journal if requested
Maintain an open mind, try new foods, beverages, recipes or activities
Eat REAL FOOD and learn to prepare it
Ask for help when needed by contacting my Pro Health Advisor
Please verify each item in the check list below.
: The purpose of the Pro Health Advisor program is to assist members with health challenges caused by certain diseases to improve their health and reduce complications.
: In many cases members with complicated diseases on good treatment programs make little or no progress towards health improvement. Frequently, the lack of success is related to misunderstandings, unaffordable medications or other barriers. Your Health Advisor's role is to help make your treatment plan work for you. In some cases this requires just some additional information or special training. Your provider may need to modify their plan because of your special circumstance. Whatever the case your Health Advisor can help.
: All members of the Western Grocers Employee Benefits Trust who have complicated diabetes, heart disease or kidney disease are eligible, but enrollment is limited.
: To encourage enrollment actively participating members are eligible for reduced deductible expenses and copays for outpatient visits (excluding ER), prescription medication (generic), and durable medical equipment related to the conditions above.
Participation: In order to be enrolled in the program and participate in the incentives members must agree to comply with the following guidelines:
Provide full access to medical information about the above conditions
Follow my health care provider's Treatment Plan and attend appointments
Discuss challenges and progress with my Pro Health Advisor monthly or as requested
Not make false statements
: Members enrolled in Pro Health Advisor program may continue to participate in the incentives until they are unable to show further health improvement or follow these standards:
Not be available for a scheduled appointment two or more consecutive times with your Pro Health Advisor or your health care provider
Not contact Pro Health Advisor for more than 30 days
Not comply with your health care provider's Treatment Plan
Dis-enrollment of members will be decided by Pro Health Advisor Board consisting of the program medical director, at least one health advisor and the trust administrator. Exceptions to policy will be considered for extraordinary situations. Members will be notified by telephone and in writing.
All of the information you provide is HIPAA protected and totally confidential except as released by you.
Although your medical claims are accessible by our Medical Director we would like for you to indicate your primary care providers (top 2).
Primary Provider 1: Name, phone, city
Primary Provider 2: Name, phone, city
I agree to the terms above
Your reimbursement begins the date your signed consent to release medical records is received in our office.
Pro Health Advisor, A patient assistance program, Medical Director: Dr. Philip Blair, MD; President: Nancy J. Weber, LD, Registered Dietitian
1880 Auburn Lane 24-H Surfside Beach, SC 29575 Voice 843-839-9088
Western Grocers Employee Benefits Trust / Cypress Benefit Administrators;
P.O.Box 22166 Portland OR 97269 Phone 800-777-3603
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