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Instructions for completing online forms
Interactive forms
(marked *)
  1. Open the form you need (requires free Adobe® Reader® software).
  2. Type in your information.
  3. E-mail it to Priority Health by clicking "File > Email" and sending it to the e-mail address printed on the form. Or fax a printed copy to the number listed on the form.
  4. Keep a copy for your records. If you have Adobe Reader, print a copy. If you have Adobe Acrobat Standard® or Pro®, you can click "File > Save as," and save the completed form to your computer.
(To check your version of Adobe, look in the top left corner of your screen when the program is open.)

Regular forms
  1. Open and print the form you need (requires free Adobe® Reader® software).
  2. Complete it.
  3. Fax it to the fax number printed on the form or scan it and e-mail it to the e-mail address printed on the form.

Forms list

Here are the most commonly used Priority Health forms for agents. Forms marked * are interactive, so you can type information right into them. You may also be able to save the completed forms to your computer. See instructions on the left.

Jump down to:

Product brochures and sales tools

Go to the products section for printable product brochures and sales information. To order a supply of product literature, contact the Small Business department or your sales representative.

Quick search

Hit CTRL+F or in your top (browser) window navigation, click Edit, then Find on this page and enter the term you're looking for.

New business forms
Forms used to enroll a group with Priority Health
Adobe PDF File *East region small group application form (844KB PDF) - Updated 07/2010 (Log-in required)
To be used by employer groups with 2-50 eligible employees. Mail all materials to Priority Health 30 days prior to the requested effective date of coverage. Priority Health requires 30 days' lead time for processing.
Adobe PDF File *West region small group application form (925KB PDF) - Updated 07/2010 (Log-in required)
To be used by employer groups with 2-50 eligible employees. Mail all materials to Priority Health 30 days prior to the requested effective date of coverage. Priority Health requires 30 days' lead time for processing.
Adobe PDF File *Large group application form (243KB PDF) - Updated 09/2009 (Log-in required)
For employer groups with 50+ eligible employees who are applying for Priority Health coverage.
Excel spreadsheet *Large group new enrollment spreadsheet (83KB XLS) - Updated 08/2010 (Log-in required)
Use this interactive spreadsheet to enroll new groups with 51+ eligible employees. Learn how to use the spreadsheet.
Word doc
Exception letters - new business (505KB DOC) - Updated 05/2009 (Log-in required)
Adobe PDF File Group Automatic Bill Payment Plan Enrollment (51KB PDF)
Allows employer groups to pay their monthly premium automatically from a checking account.
Adobe PDF File *Group Eligibility/Coverage Confirmation Affidavit (60KB PDF) - Updated 05/2009
Adobe PDF File 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.
Adobe PDF File *Proposal Request Sheet (195KB PDF) - Updated 01/2010 (Log-in required)
Use this form to request a proposal for a small business group if you are unable to use Rate Generator. Make sure you submit a Census Form, too.
Excel spreadsheet *Census Form (64KB XLSM)
Submit this form with the Proposal Request Sheet.
Adobe PDF File Small group eligibility guidelines (32KB PDF) - Updated 01/2009
For groups of 1-50 eligible employees
Adobe PDF File Sponsored dependent eligibility guidelines (48KB PDF) - Updated 06/2008
Guidelines are in addition to covered dependent's eligibility requirements
Adobe PDF File Employee Coverage Waiver (184KB PDF) - Updated 03/2010
For use with groups of 1-50 employees to waive Priority Health coverage
Adobe PDF File Service area map (676KB PDF)
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
Word doc
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.
Adobe PDF File Medicare Part D - MAPD employer group agreement (25KB PDF) - Updated 07/2010 (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.
Adobe PDF File Medicare Part D - PDP (drug plan only) employer group agreement (24K PDF) - Updated 07/2010 (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.
Adobe PDF File *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).
Adobe PDF File *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.
Individual Priority Health Medicare plans
Adobe PDF File Medicare sales appointment confirmation form (476KB PDF) - Updated 06/2010
Required for any face-to-face marketing appointment with a beneficiary.
Adobe PDF File 2010 Medicare Advantage plan enrollment form (465KB PDF) - Updated 11/2009
For faster enrollment, use the online MAPD plan enrollment form at prioritymedicare.com. You'll have to choose a county and a plan.
Adobe PDF File 2010 Medicare Drug Plan enrollment form (242KB PDF) - Updated 11/2009
For faster enrollment, use the online Rx plan enrollment form at prioritymedicare.com. You'll have to choose a county.
Adobe PDF File *Medigap (Medicare Supplement insurance) plan application form (148KB PDF) - Updated 12/2009
Use to apply for coverage under any one of three Priority Health plans (A, C or F).
For faster processing, use the online application form at prioritymedicare.com.
Adobe PDF File Priority Health Medicare Advantage plan change form (449KB PDF) - Added 03/2010
Have your client fill out this form when they would like to change Priority Health Medicare Advantage plans.
PriorityFSA
Adobe PDF File *PriorityFSA rates and instructions sheet (27KB PDF) - Updated 01/2009
Adobe PDF File *PriorityFSA application - large business groups (330KB PDF) - Updated 04/2010
Adobe PDF File *PriorityFSA application - small business groups (107KB PDF) - Updated 08/2009
Adobe PDF File *PriorityFSA adoption agreement (77KB PDF) - Updated 11/2008
To be filled out by an employer group that has PriorityFSA.
Adobe PDF File *PriorityFSA small group renewal checklist (464KB PDF) - Updated 11/2009
Use this checklist to help with renewing a small group's FSA plan.
Adobe PDF File *PriorityFSA summary plan document - health care FSA only (207 KB PDF) - Updated 04/2009
For small business groups that have a health care FSA plan only
Adobe PDF File *PriorityFSA summary plan document - health care FSA with dependent care reimbursement (242 KB PDF) - Updated 04/2009
For small business groups that have a health care FSA plan combined with dependent care reimbursement
Adobe PDF File *PriorityFSA summary plan document - limited health care FSA with dependent care reimbursement (448 KB PDF) - Updated 04/2009
For small business groups with an HSA plan using a limited health care FSA with dependent care reimbursement
Adobe PDF File *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
Adobe PDF File *Flexible Spending Account (FSA) withdrawal request (169KB PDF) - Updated 02/2010
Adobe PDF File *Limited FSA withdrawal request form for HSA (157KB PDF) - Updated 02/2010
Adobe PDF File *Flexible Spending Account (FSA) enrollment/change form (139KB PDF) - Updated 02/2010
PriorityHRA
Adobe PDF File *PriorityHRA application form (63KB PDF) - Updated 05/2009
Use this application for PriorityMRA, too.
Adobe PDF File *PriorityHRA summary plan documents (190KB PDF) - Updated 05/2009
Adobe PDF File *PriorityHRA non-ERISA summary plan documents (290KB PDF) - Updated 05/2009
Adobe PDF File *PriorityMRA plan documents (513KB PDF) - Updated 06/2010
HealthbyChoice Incentives
Adobe PDF File *HealthbyChoice Incentives no wrap form (53KB PDF) - Updated 04/2009
For large groups who are renewing or switching to a HealthbyChoice Incentives plan. Have them fill out the form and include it in their renewal packet.
Adobe PDF File HealthbyChoice Incentives Qualification form (99KB PDF) - Updated 02/2010
PriorityHSA
Adobe PDF File *HSA member deductible credit request form (179KB PDF) - Updated 04/2010
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.
Adobe PDF File *HSA 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.
Renewal forms
Forms used to renew a group's coverage
Word doc Exception letters - renewals (509KB DOC) - Updated 05/2009 (Log-in required)
Adobe PDF File Group eligibility/coverage confirmation affidavit (60KB PDF) - Updated 05/2009

Renewal Verification Forms (RVFs) are located in Rate Generator.
Member forms
Forms members need to fill out
Adobe PDF File *Change form (44KB PDF) - Updated 03/2005
To make changes to a member's name, contact information or dependent status
Adobe PDF File *Change PCP (29KB PDF)
For a member to change his/her primary care physician
Adobe PDF File *Enrollment form (353KB PDF) - Updated 02/2010
Adobe PDF File Attending physician statement (526KB 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.
Adobe PDF File Affidavit for domestic partner benefits - for same and opposite gender partners (53KB PDF) - Updated 01/2009
Adobe PDF File Affidavit for domestic partner benefits - for same gender partners (60KB PDF) - Updated 01/2009
Adobe PDF File *Disability claim form (171KB PDF) - Updated 03/2010
Adobe PDF File HIPAA authorization (53KB PDF) - Updated 05/2010
Adobe PDF File HIPAA authorization, Spanish (98KB PDF) - Updated 05/2010
Adobe PDF File Revocation of HIPAA authorization (61KB PDF) - Updated 05/2010
Adobe PDF File Revocation of HIPAA authorization, Spanish (57KB PDF) - Updated 05/2010
Agent forms
Forms you use to do business with us
Adobe PDF File *Agent Agreement (614KB PDF) - Updated 04/2010
Adobe PDF File *Agent Agreement transfer amendment (352KB PDF) - Added 06/2010
Submit this form to continue your Priority Health appointment when you transfer to a different agency or start working as an individual agent.
Adobe PDF File *Agent Agreement amendment (47KB PDF) - Added 04/2010
For agreements signed before April 1, 2010.
Adobe PDF File Agent commission direct deposit agreement (31KB PDF)
Adobe PDF File Agent of record checklist (18KB PDF) - Updated 04/2005
Adobe PDF File Key Producer election form - (70KB PDF) - Updated 03/2010 (Log-in required)
Adobe PDF File 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.
Web page Request to access employer tools
Submit this form to request access to an employer group's online functions via your own Priority Health password
Adobe PDF File *Request for supplies form (60KB PDF) - Updated 08/2010


*This form is interactive, so you can type information right into it, then print it off and send it to us.


Last modified 08/26/10