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 (732KB PDF) - Updated 11/2009 (Log-in required) 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 form (818KB PDF) - Updated 11/2009 (Log-in required) 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 form (243KB PDF) - Updated 09/2009 (Log-in required) For employer groups with 50+ eligible employees who are applying for Priority Health coverage.
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 - (491KB PDF) Updated 09/2008 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 (172KB PDF) - Updated 11/2009 (Log-in required) Use this form to request a proposal for a small business group if you are unable to use Rate Generator.
	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 (18KB PDF) For use with reform groups of 1-50 employees to waive Priority Health coverage
Word doc	Group Roster Worksheet (283KB MS Word DOC)
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 employer group agreement (25KB PDF) - Updated 07/2008 (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 plan group enrollment form (86KB PDF) - Updated 06/2006 (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 (60KB PDF) - Updated 06/2009 (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 (65KB PDF) - Updated 10/2009 Required for any face-to-face marketing appointment with a beneficiary.
PriorityFSA
	*PriorityFSA rates and instructions sheet (27KB PDF) - Updated 01/2009
	*PriorityFSA application - large business groups (202KB PDF) - Updated 08/2009
	*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 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 (148KB PDF) - Updated 01/2009
	*Limited FSA withdrawal request form for HSA (142KB PDF) - Updated 01/2009
	*Flexible Spending Account (FSA) enrollment/change form (98KB PDF) - Updated 01/2009
PriorityHRA
	*PriorityHRA application form (63KB PDF) - Updated 05/2009
	*PriorityHRA summary plan documents (190KB PDF) - Updated 05/2009
	*PriorityHRA non-ERISA summary plan documents (290KB PDF) - Updated 05/2009
	*PriorityMRA plan documents (494KB PDF) - Updated 05/2009
HealthbyChoice Incentives
	HealthbyChoice Incentives Qualification form (79KB PDF) - Updated 07/2007
	HealthbyChoice Incentives No Wrap Form (49KB PDF) - Updated 04/2009
PriorityHSA
	HSA member deductible credit request form (119KB PDF) - Updated 11/2008 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.
	PriorityHSA No Wrap Form (53KB PDF) - Updated 04/2009
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 09/2009
	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
	*Claim form (100KB PDF) - Updated 04/2008
	Disability claim form (608KB PDF) - Updated 11/2009
	HIPAA authorization (33KB PDF) - Updated 10/2006
	HIPAA authorization, Spanish (34KB PDF) - Updated 10/2006
	Revocation of HIPAA authorization (32KB PDF) - Updated 10/2006
	Revocation of HIPAA authorization, Spanish (33KB PDF) - Updated 10/2006
Agent forms
Forms you use to do business with us
	Agent Agreement (609KB PDF) - Updated 10/2009 The agent agreement was amended on 10/23/2009 to comply with the Federal Health Information Technology for Economic and Clinic Health Act. Agents who completed an agreement before 10/23/2009 may reference the old agent agreement with the amendment attached here.
	Agent commission direct deposit agreement (31KB PDF)
	Agent of record checklist (18KB PDF) - Updated 04/2005
	Key Producer election form - (70KB PDF) - Updated 10/2009 (Log-in required)
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 (32KB PDF) - Updated 10/2009