<PAGE>
U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM 4 OMB APPROVAL
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[_] Check this box if no longer OMB NUMBER: 3235-0287
subject to Section 16. Form 4 Expires: April 30, 1997
or Form 5 obligations may Estimated average burden
continue. SEE Instruction 1(b). hours per response ...... 0.5
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STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934,
Section 17(a) of the Public Utility Holding Company Act of 1935 or
Section 30(f) of the Investment Company Act of 1940
1. Name and Address of Reporting Person
Herbert Michael E.
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(Last) (First) (Middle)
120 Hawley Lane
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(Street)
Trumbull CT 06611
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(City) (State) (Zip)
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2. Issuer Name and Ticker or Trading Symbol
Physicians Health Services, Inc. (PHSV)
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3. IRS or Social Security Number of Reporting Person (Voluntary)
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4. Statement for Month/Year
December 1996
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5. If Amendment, Date of Original (Month/Year)
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6. Relationship of Reporting Person to Issuer
(Check all applicable)
X Director X 10% Owner
----- ------
X Officer (give Other (Specify
----- title below) ------ below)
Third Vice Chairman & Co-Chief
Executive Officer
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<TABLE>
<CAPTION>
Table 1 -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security 2. Trans- 3. Trans- 4. Securities Acquired (A) 5. Amount of 6. Ownership 7. Nature
(Instr. 3) action action or Disposed of (D) Securities Form: of Indirect
Date Code Beneficially Direct Beneficial
(Instr. 8) (Instr. 3,4 and 5) Owned at (D) or Ownership
(Month/ ------------ -------------------------- End of Month Indirect (Instr. 4)
Day/ Code V Amount (A) or Price (Instr. 3 (I)
Year) (D) and 4) (Instr. 4)
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<S> <C> <C> <C> <C> <C> <C> <C> <C> <C>
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Class A Common Stock 12/09/1996 G 2,800 D 39,200 D
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Class A Common Stock 12/09/1996 G 2,800 A 4,670 I by spouse as
Trustee
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Class A Common Stock 9,500 I by ex-spouse
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</TABLE>
<PAGE>
FORM 4 (continued)
<TABLE>
<CAPTION>
Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative 2. Conversion 3. Transaction 4. Transacation 5. Number of Derivative 6. Date Exercisable
Security (Instr. 3) or Exercise Date Code Securities Acquired (A) and Expiration
Price of (Month/Day/ (Instr. 8) or Disposed of (D) Date
Derivative Year) (Instr. 3, 4, and 5) (Month/Day/
Security Year)
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Code V (A) (D) Date Expiration
Exer- Date
cisable
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<S> <C> <C> <C> <C> <C> <C> <C> <C>
Class B Common
Stock (01)
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Non-Qualified $15.0000 01/05/1994 01/05/2003
Stock Options (02)
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Non-Qualified $20.3700 01/15/1995 01/15/2004
Stock Options (03)
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Non Qualified $23.5000 01/10/1996 01/10/2005
Stock Options (04)
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Non-Qualified $38.7508 01/30/1997 01/30/2006
Stock Options (05)
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Class B Common
Stock (01)
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- --------------------------- -------------- -------------- -------- ----- --------------- ---------- ---------- ----------
- --------------------------- -------------- -------------- -------- ----- --------------- ---------- ---------- ----------
</TABLE>
<TABLE>
<CAPTION>
7. Title and Amount of 8. Price of Derivative 9. Number of Derivative 10. Ownership Form 11. Nature of Indirect
Underlying Securities Security (Instr. 5) Securities Beneficially of Derivative Security: Beneficial Ownership
(Instr. 3 and 4) Owned at End of Month Direct (D) or (Instr. 4)
Instr. 4) Indirect (I) (Instr. 4)
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Title Amount or
Number of
Shares
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<S> <C> <C> <C> <C>
Class A 439,873 439,873 D
Common Stock
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Class A 20,720 20,720 D
Common Stock
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Class A 27,100 27,100 D
Common Stock
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Class A 65,552 65,552 D
Common Stock
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Class A 44,244 44,244 D
Common Stock
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Class A 7,500 7,500 I by spouse as Trustee
Common Stock
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- ------------------------ ---------------------- -------------------------- --------------------------- ------------------------
- ------------------------ ---------------------- -------------------------- --------------------------- ------------------------
</TABLE>
Explanation of Responses:
(01) Convertible one for one to Class A
(02) vests in three annual installments, commencing 1/03/94
(03) vests in three annual installments, commencing 1/15/95
(04) vests in three annual installments, commencing 1/10/96
(05) vests in three annual installments, commencing 1/30/97
**Intentional misstatements or omissions of facts constitute Federal Criminal
Violations.
See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
_______________________________ ______________
**Signature of Reporting Person Date
Note: File three copies of this Form, one of which must be manually signed. If
space provided is insufficient, See Instruction 6 for procedure.
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SEC 1474 (8-92)
