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Agent Forms

Here is all information you need to work with Priority Health: forms, product brochures, member educational tools, etc.

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New business forms

East region Small Group Application (136KB PDF) - Updated 06/2008 (Must be logged in to view.)
To be used by employer groups with 2-50 eligible employees who are applying for Priority Health coverage. This application should be submitted to Priority Health by the first of the month before coverage is to begin.

West region Small Group Application (547KB PDF) - Updated 03/2008 (Must be logged in to view.)
To be used by employer groups with 1-50 eligible employees who are applying for Priority Health coverage. This application should be submitted to Priority Health by the first of the month before coverage is to begin.

Large Group Application (125KB PDF) - Updated 08/2007 (Must be logged in to view.)
For employer groups with 50+ eligible employees who are applying for Priority Health coverage.

Group Automatic Bill Payment Plan (51KB PDF)

Exception letters - new business (504KB DOC) - Updated 08/2006 (Must be logged in to view.)

Agent forms

Request to Access Employer Tools
Submit this form to request access to an employer group's online functions via your own Priority Health password

Agent Agreement (1.1MB PDF) - Updated 10/2007

Agent of Record Checklist (18KB PDF)

Agent commission direct deposit agreement (31KB PDF)

Key Producer Election Form (48KB PDF) - Updated 12/2006 (Must be logged in to view.)

Request for supplies (32KB PDF) - Updated 06/2008

Enrollment/change forms

ASO Change/Election (36KB PDF)

Change PCP (29KB PDF)

Change of Status (44KB PDF) - Updated 03/2005
To make changes to a member's name, contact information or dependent status

EPO/POS Enrollment Change of Status (259KB PDF)

Flexible Spending Account (FSA) Enrollment/Change (505KB PDF) - Updated 08/2008

HealthbyChoice Incentives Qualification Form (79KB PDF) - Updated 07/2007

HMO and POS Enrollment, form PH602 (352KB PDF) - Updated 08/2008

POS Enrollment/Change of Status (95KB PDF - prints 8-1/2 x 14) - Updated 10/2003

PPO/Indemnity Change of Status (268KB PDF) - Updated 03/2001

Revocation of HIPAA Authorization (32KB PDF) - Updated 10/2006

Claim, physician and other forms

Attending Physician Statement (113KB PDF) - Updated 05/2005
To be completed by employee's physician when employee is applying for short-term disability (STD) benefits.
To be used only by employer groups/employees for whom Priority Health provides STD services.

Claim Form (74KB PDF) - Updated 01/2007

Disability Claim (428KB PDF) - Updated 05/2005

Employee Waiver (18KB PDF)
For use with reform groups of 1-50 employees to waive Priority Health coverage

Flexible Spending Account (FSA) Withdrawal Request (120KB PDF) - Updated 06/2006

HIPAA Authorization (33KB PDF) - Updated 10/2006

Renewal forms

Exception letters - renewals (504KB DOC) - Updated 08/2006 (Log-in required)

Group Roster Worksheet (283KB MS Word DOC)

Instructions for completing and submitting PDF forms

To submit a form:
STEP 1: Open and print the form you need (requires free Adobe Acrobat Reader)
STEP 2: Complete and sign it.
STEP 3: Mail or fax it to the address or fax number printed on the form.

Last modified 08/28/08