| New business forms |
| Forms used to enroll a group with Priority Health |
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Use ClientManagerSM for all new small group applications. We no longer accept paper applications for new small groups choosing Priority Health coverage. |
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*Large group application form (270KB PDF) - Updated 12/2010 (Log-in required)
For employer groups with 50+ eligible employees who are applying for Priority Health coverage. |
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*Large group new enrollment spreadsheet (216KB XLS) - Updated 01/2011 (Log-in required)
Use this interactive spreadsheet to enroll new groups with 51+ eligible employees. Learn how to use the spreadsheet |
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Exception letters - new business (880KB DOC) - Updated 12/2010 (Log-in required)
Use for small groups with HMO, PPO, POS, HSA or HRA plans. |
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HBC Exception letters - new business (885KB DOC) - Updated 12/2010 (Log-in required)
Use for small groups with HealthbyChoice Achievements. |
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Group Automatic Bill Payment Plan Enrollment (395KB PDF)
Allows employer groups to pay their monthly premium automatically from a checking account. |
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*Group Eligibility/Coverage Confirmation Affidavit (60KB PDF) - Updated 05/2009 |
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Deductible Credit Request form - (495KB PDF) Updated 02/2010
Allows new members who met part of their current year deductible with a previous health plan to be reimbursed for that amount by Priority Health. |
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Sponsored dependent eligibility guidelines (41KB PDF) - Updated 11/2010
Guidelines are in addition to covered dependent's eligibility requirements |
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Employee Coverage Waiver (30KB PDF) - Updated 02/2012
For use with groups of 2-50 employees to waive Priority Health coverage |
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Service area map (787KB PDF) - Updated 12/2011
Printable map shows where you can quote Priority Health. Map includes a list of hospitals that participate in our HMO and/or PPO plans. |
| Product-specific forms |
| Forms for enrolling in and using certain products |
| Group Priority Health Medicare plans |
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30-day employer notification letter (27KB DOC) - Updated 08/2008 (Log-in required)
Employer groups should send this letter to all retirees (not spouses) eligible for Medicare benefits 30 days before the plan's effective date. |
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Medicare Part D - MAPD employer group agreement (95KB PDF) - Updated 03/2011 (Log-in required)
Every group that chooses a Medicare Advantage Part D (MAPD) plan must sign a group agreement with Priority Health. NOTE: The group agreement is updated regularly. Check to verify the form here matches your most recent copy. |
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Medicare Part D - PDP (drug plan only) employer group agreement (91KB PDF) - Updated 03/2011 (Log-in required)
Every group that chooses a Medicare Part D Prescription Drug Plan (PDP) plan must sign a group agreement with Priority Health. NOTE: The group agreement is updated regularly. Check to verify the form here matches your most recent copy. |
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*Medicare plan group enrollment form (126KB PDF) - Updated 03/2010 (Log-in required)
Each retiree must fill this form out. NOTE: Retiree/spouse signature must be documented prior to the first of the month the plan starts (a plan effective 12/01/2009 must be signed on or before 11/30/2009). |
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*Medicare retiree verification form (174KB PDF) - Updated 05/2010 (Log-in required)
Confirms which of the group's employees are eligible for group Medicare coverage. |
| HealthbyChoice |
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HealthbyChoice Certification (no wrap) form (80KB PDF) - Updated 12/2011
For large groups who are renewing or switching to a HealthbyChoice plan. Have them fill out the form and include it in their renewal packet. |
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HealthbyChoice Qualification forms:
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| Individual Priority Health Medicare plans |
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Medicare sales appointment confirmation form (97KB PDF) - Updated 09/2011
Required for any face-to-face marketing appointment with a beneficiary. Fax completed form to 616 942-7204 or scan and email to phmedicareenrollment@priorityhealth.com. |
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*2012 Medicare Advantage plan enrollment form (216KB PDF) - Updated 01/2012
For faster enrollment, use the online MAPD plan enrollment form at priorityhealth.com/medicare. You'll have to choose a county and a plan. |
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*2012 Medicare Drug Plan enrollment form (195KB PDF) - Updated 10/2011
For faster enrollment, use the online Rx plan enrollment form at priorityhealth.com/medicare. You'll have to choose a county. |
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*Medigap (Medicare Supplement) plan application form (140KB PDF) - Updated 11/2010
Use to apply for coverage under any one of four Priority Health plans (A, D, F or N).
For faster processing, use the online application form at priorityhealth.com/medicare. |
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*Automatic Bill Payment sign-up form (72KB PDF) - Updated 02/2011
Use this to have premiums automatically deducted from your client's bank account by electronic funds transfer (EFT). |
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*Enhanced Dental plan enrollment form (227KB PDF) - Updated 09/2011
Also use the online Enhanced Dental plan enrollment form. |
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2012 Plan Selection form
For clients switching to our PriorityMedicare plan from PriorityMedicare Value plan (or vice versa). You can also use the PDF version - download 2012 Plan Selection Form (74KB PDF) - Updated (09/2011) |
| MyPriority Plans |
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MyPriority application (784KB PDF) - Updated 03/2011 |
| PriorityFSA |
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*PriorityFSA application - large business groups (330KB PDF) - Updated 04/2010 |
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*PriorityFSA adoption agreement (77KB PDF) - Updated 11/2008
To be filled out by an employer group that has PriorityFSA. |
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*PriorityFSA small group renewal checklist (464KB PDF) - Updated 11/2009
Use this checklist to help with renewing a small group's FSA plan. |
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*PriorityFSA summary plan document - health care FSA only (207KB PDF) - Updated 04/2009
For small business groups that have a health care FSA plan only |
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*PriorityFSA summary plan document - health care FSA with dependent care reimbursement (242KB PDF) - Updated 04/2009
For small business groups that have a health care FSA plan combined with dependent care reimbursement |
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*PriorityFSA summary plan document - limited health care FSA with dependent care reimbursement (448KB PDF) - Updated 04/2009
For small business groups with an HSA plan using a limited health care FSA with dependent care reimbursement |
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*PriorityFSA summary plan document - traditional and limited health care FSAs with dependent care (449KB PDF) - Updated 04/2009
For small business groups offering both a traditional health plan and HSA with traditional and limited health care FSAs combined with dependent care reimbursement |
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*Flexible Spending Account (FSA) withdrawal request (194KB PDF) - Updated 11/2010 |
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*Limited FSA withdrawal request form for HSA (234KB PDF) - Updated 12/2010 |
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*Flexible Spending Account (FSA) enrollment/change form (135KB PDF) - Updated 11/2010 |
| PriorityHRA |
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*PriorityHRA application form (63KB PDF) - Updated 05/2009
Use this application for PriorityMRA, too. |
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*PriorityHRA summary plan documents (190KB PDF) - Updated 03/2012 |
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*PriorityHRA non-ERISA summary plan documents (290KB PDF) - Updated 03/2012 |
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*PriorityMRA plan documents (298KB PDF) - Updated 03/2012 |
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*PriorityHRA administrative services agreement (141KB PDF) - Updated 03/2012 |
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*PriorityHRA HIPAA business associate agreement (458KB PDF) - Updated 03/2012 |
| PriorityHSA |
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*HSA member deductible credit request form (179KB PDF) - Updated 11/2011
Allows new members with PriorityHSA who met part of their current year deductible with a previous health plan to be reimbursed for that amount by Priority Health. |
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*HSA Certification (no wrap) form (58KB PDF) - Updated 04/2009
For large groups who are renewing or switching to a PriorityHSA plan. Have them fill out the form and include it in their renewal packet. |
| PriorityValue |
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*PriorityValue Certification (no wrap) form (29KB PDF) - Updated 12/2011
For large groups who are renewing or switching to a PriorityValue plan. Have them fill out the form and include it in their renewal packet. |
| Renewal forms |
| Forms used to renew a group's coverage |
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Certification of owner form (18KB PDF) - Updated 11/2010
Have each owner of your renewing group complete this form only (bold) if the owner is currently covered on the health plan but not listed on the Quarterly Wage Detail Report (QWDR). |
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Exception letters - renewals (663KB DOC) - Updated 12/2010 (Log-in required)
Use for small groups with HMO, PPO, POS, HSA or HRA plans.
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HBC Exception letters - renewals (674KB DOC) - Updated 12/2010 (Log-in required)
Use for small groups with HealthbyChoice Incentives or HealthbyChoice Achievements. |
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Group eligibility/coverage confirmation affidavit (60KB PDF) - Updated 05/2009 |
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Renewal Verification Forms (RVFs) are located in Rate Generator. |
| Member forms |
| Forms members need to fill out |
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*Change form (925KB PDF) - Updated 12/2010
To make changes to a member's name, contact information or dependent status |
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*Change PCP (1.6MB PDF) - Updated 06/2010
For a member to change his/her primary care physician |
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*Enrollment form (718KB PDF) - Updated 12/2010 |
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*Member reimbursement form (470KB PDF) - Updated 04/2010 |
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Attending physician statement (864KB 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. |
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Affidavit for domestic partner benefits - for same and opposite gender partners (51KB PDF) - Updated 01/2009 |
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Affidavit for domestic partner benefits - for same gender partners (53KB PDF) - Updated 01/2009 |
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*Disability claim form (171KB PDF) - Updated 03/2010 |
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*HIPAA authorization (323KB PDF) - Updated 02/2012 |
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*HIPAA authorization, Spanish (332KB PDF) - Updated 02/2012 |
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Revocation of HIPAA authorization (99KB PDF) - Updated 05/2010 |
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Revocation of HIPAA authorization, Spanish (37KB PDF) - Updated 05/2010 |
| Agent forms |
| Forms you use to do business with us |
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*Group health plans agent agreement (127KB PDF) - Updated 04/2012
Submit this form if you want to sell group Priority Health plans. To sell MyPriority or Medicare Advantage plans: learn how. |
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*Group agent agreement transfer amendment (391KB PDF) - Updated 04/2012
Submit this form to continue your Priority Health group plans appointment when you transfer to a different agency or start working as an individual agent. |
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*Individual plan agent agreement (899KB PDF) - Updated 04/2012
Submit this form if you want to sell individual Priority Health plans. |
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*Individual plan agent agreement transfer amendment (343KB PDF) - Added 04/2012
Submit this form to continue your Priority Health individual plans appointment when you transfer to a different agency. |
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*Agent commission direct deposit agreement (80KB PDF) - Updated 04/2012 |
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Agent of record checklist - Updated 08/2011 |
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Release of information checklist - Updated 08/2011 |
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Key Producer election form - Updated 11/2010 (Log-in required)
2011 program enrollment deadline was December 15, 2010. |
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Medigap Amendment to the Agent Agreement - (70KB PDF) - Updated 02/2010
Existing agents (those who signed an Agent Agreement with us before 10/2009) who want to sell Priority Health Medigap products must fill out and submit this amendment. |
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Request to access employer tools
Submit this form to request access to an employer group's online functions via your own Priority Health password |
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*Group health plans supply order form (58KB PDF) - Updated 03/2012 |
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*Medicare supply order form (103KB PDF) - Updated 05/2012 |
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*MyPriority supply order form (50KB PDF) - Updated 04/2011 |
