Agent Forms

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:

• New business forms
• Product-specific forms
• Renewal forms
• Member forms
• Agent forms

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
	*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.
	*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.
	*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)
	Group Automatic Bill Payment Plan Enrollment (51KB PDF) Allows employer groups to pay their monthly premium automatically from a checking account.
	*Group Eligibility/Coverage Confirmation Affidavit (60KB PDF) - Updated 05/2009
	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.
	*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.
	Small group eligibility guidelines (32KB PDF) - Updated 01/2009 For groups of 1-50 eligible employees
	Sponsored dependent eligibility guidelines (48KB PDF) - Updated 06/2008 Guidelines are in addition to covered dependent's eligibility requirements
	Employee Coverage Waiver (184KB PDF) - Updated 03/2010 For use with groups of 1-50 employees to waive Priority Health coverage
	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.
	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.
	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.
	*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).
	*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
	Medicare sales appointment confirmation form (476KB PDF) - Updated 06/2010 Required for any face-to-face marketing appointment with a beneficiary.
	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.
	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.
	*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.
	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
	*PriorityFSA rates and instructions sheet (27KB PDF) - Updated 01/2009
	*PriorityFSA application - large business groups (330KB PDF) - Updated 04/2010
	*PriorityFSA application - small business groups (107KB PDF) - Updated 08/2009
	*PriorityFSA adoption agreement (77KB PDF) - Updated 11/2008 To be filled out by an employer group that has PriorityFSA.
	*PriorityFSA small group renewal checklist (464KB PDF) - Updated 11/2009 Use this checklist to help with renewing a small group's FSA plan.
	*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
	*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
	*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
	*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
	*Flexible Spending Account (FSA) withdrawal request (169KB PDF) - Updated 02/2010
	*Limited FSA withdrawal request form for HSA (157KB PDF) - Updated 02/2010
	*Flexible Spending Account (FSA) enrollment/change form (139KB PDF) - Updated 02/2010
PriorityHRA
	*PriorityHRA application form (63KB PDF) - Updated 05/2009 Use this application for PriorityMRA, too.
	*PriorityHRA summary plan documents (190KB PDF) - Updated 05/2009
	*PriorityHRA non-ERISA summary plan documents (290KB PDF) - Updated 05/2009
	*PriorityMRA plan documents (513KB PDF) - Updated 06/2010
HealthbyChoice Incentives
	*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.
	HealthbyChoice Incentives Qualification form (99KB PDF) - Updated 02/2010
PriorityHSA
	*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.
	*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)
	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
	*Change form (44KB PDF) - Updated 03/2005 To make changes to a member's name, contact information or dependent status
	*Change PCP (29KB PDF) For a member to change his/her primary care physician
	*Enrollment form (353KB PDF) - Updated 02/2010
	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.
	Affidavit for domestic partner benefits - for same and opposite gender partners (53KB PDF) - Updated 01/2009
	Affidavit for domestic partner benefits - for same gender partners (60KB PDF) - Updated 01/2009
	*Disability claim form (171KB PDF) - Updated 03/2010
	HIPAA authorization (53KB PDF) - Updated 05/2010
	HIPAA authorization, Spanish (98KB PDF) - Updated 05/2010
	Revocation of HIPAA authorization (61KB PDF) - Updated 05/2010
	Revocation of HIPAA authorization, Spanish (57KB PDF) - Updated 05/2010
Agent forms
Forms you use to do business with us
	*Agent Agreement (614KB PDF) - Updated 04/2010
	*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.
	*Agent Agreement amendment (47KB PDF) - Added 04/2010 For agreements signed before April 1, 2010.
	Agent commission direct deposit agreement (31KB PDF)
	Agent of record checklist (18KB PDF) - Updated 04/2005
	Key Producer election form - (70KB PDF) - Updated 03/2010 (Log-in required)
	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
	*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.