Employer forms

Forms list

Here are all of the most commonly used Priority Health forms for employers. 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:

• Employer forms
• Enrollment/change forms
• Claim, physician, reimbursement and other forms
• Report guides
• Instructions for submitting PDF forms

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Employer Forms
Forms to be filled out by your company's benefits administrator
	Request to Access Employer Online Information (online form for agents) Agents can use this form to request permission from you and Priority Health to access your online information.
	*Group Automatic Bill Payment Plan Enrollment (399KB PDF) Sign up to have your monthly premium automatically withdrawn from your checking account.
	*Large group application form (142KB PDF) - Updated 10/2008 (Log-in required) For employer groups with 50+ eligible employees who are applying for Priority Health coverage.
	*Request for Supplies form (60KB PDF) - Updated 08/2010
	*East region small group application form (845KB PDF) - Updated 07/2010 (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 (925KB PDF) - Updated 07/2010 (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.
	PriorityFSA Adoption Agreement (77KB PDF) - Updated 11/2008 To be filled out by an employer group that has PriorityFSA
	*PriorityFSA Application - Small Business Group (55KB PDF) - Updated 02/2009
	*PriorityFSA Application - Large Business Group (330KB PDF) - Updated 04/2010
	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.
Word doc	Sample Summary Plan Description (SPD "Wrap") instructions and template (168KB DOC) - Updated 07/2010
Enrollment/change forms
To be filled out by your employees when they enroll in or change their coverage.
	*Change PCP (3.0MB PDF) - Updated 06/2010 For a member to change his/her primary care physician (PCP)
	*Change of Status form (514KB PDF) - Updated 06/2010 To make changes to a member's name, contact information or dependent status or to terminate a member's coverage To disenroll an employee: fill out the green section at the bottom of the page
	*Employee Coverage Waiver (186KB PDF) - Updated 06/2010 Have employees fill this out when they want to waive Priority Health coverage.
	*Enrollment form (763KB PDF) - Updated 06/2010
	*Flexible Spending Account (FSA) Enrollment/Change (531KB PDF) - Updated 06/2010 To enroll in or make changes to FSA benefits under a 125 plan.
Claim, physician, reimbursement and other forms
To be filled out by employees when they need to visit their physicians, request services or give authorization for service.
	*Attending Physician Statement (864KB PDF) - Updated 04/2010 To be completed by a physician when applying for short-term disability (STD) benefits covered by Priority Health.
	*Disability claim form (171KB PDF) - Updated 03/2010 To be completed when an employee is applying for short-term disability (STD) benefits you offer through Priority Health.
	*Flexible Spending Account (FSA) Withdrawal Request (1169KB PDF) - Updated 02/2010 To request withdrawals from FSA accounts (medical and dependent care).
	HealthbyChoice Incentives Qualification Form (99KB PDF) - Updated 02/2010
	*HIPAA Authorization (53KB PDF) - Updated 05/2010
	*HIPAA Authorization, Spanish (98KB PDF) - Updated 05/2010
	*HSA Member Deductible Credit Request form (179KB PDF) - Updated 04/2010 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.
	*Limited FSA Withdrawal Request form for HSA (157KB PDF) - Updated 02/2010
	*Member Reimbursement form (470KB PDF) - Updated 04/2010
	*Revocation of HIPAA Authorization (61KB PDF) - Updated 05/2010
	*Revocation of HIPAA Authorization, Spanish (57KB PDF) - Updated 05/2010
	Walgreens Mail Service Registration & Prescription Order (56KB PDF) - Updated 02/200
	Walgreens Mail Service Fax Order form (51KB PDF) - Updated 03/2005
Report Guides
How to use the monthly reports you receive from Priority Health.
Web page	*Financial Summary Guide (for shared funding groups) Use this monthly report to gauge how closely your actual claims experience matches what was projected at the start of the plan year.
Web page	*Network Performance and Benefit Design Summary Guide (for shared funding groups) Use this monthly report to gauge operational and provider network performance as well as utilization patterns.

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