Employer forms

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

Jump down to:
Employer forms
Enrollment/change forms
Claim, physician, reimbursement and other forms
Report guides
Instructions for submitting PDF forms

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 (51KB 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Sign up to have your monthly premium automatically withdrawn from your checking account.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 (32KB PDF) - Updated 10/2009

East region small group application form (245KB PDF) - Updated 05/2009 (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 (250KB PDF) - Updated 05/2009 (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.

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

Sample Summary Plan Description (SPD "Wrap") Instructions and Template (80KB PDF); use this one to cut and paste text (137KB DOC)

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Enrollment/change forms

To be filled out by your employees when they enroll in or change their coverage. They can e-mail completed forms to enroll@priorityhealth.com.

Change PCP (29KB PDF)
For a member to change his/her primary care physician (PCP)

Change of Status form (44KB PDF) - Updated 03/2005
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 (80KB PDF)
Have employees fill this out when they want to waive Priority Health coverage.

Enrollment form (353KB PDF) - Updated 09/2009

Flexible Spending Account (FSA) Enrollment/Change (142KB PDF) - Updated 01/2009
To enroll in or make changes to FSA benefits under a 125 plan.

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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 (526KB PDF) - Updated 05/2005
To be completed by a physician when applying for short-term disability (STD) benefits covered by Priority Health.

Claim form (100KB PDF) - Updated 04/2008

Disability claim form (603KB PDF) - Updated 11/2009
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 (98KB PDF) - Updated 01/2009
To request withdrawals from FSA accounts (medical, dependent care, adoption assistance).

HealthbyChoice Incentives Qualification Form (68KB PDF) - Updated 07/2007

HIPAA Authorization (33KB PDF) - Updated 10/2006

HIPAA Authorization, Spanish (38KB PDF) - Updated 10/2006

HSA Member Deductible Credit Request form (119KB PDF) - Updated 11/2008
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.

Limited FSA Withdrawal Request form for HSA (142KB PDF) - Updated 01/2009

Member Reimbursement form (62KB PDF) - Updated 01/2007

Revocation of HIPAA Authorization (32KB PDF) - Updated 10/2006

Revocation of HIPAA Authorization, Spanish (33KB PDF) - Updated 10/2006

Walgreens Mail Service Registration & Prescription Order (56KB PDF) - Updated 02/2005

Walgreens Mail Service Fax Order form (51KB PDF) - Updated 03/2005

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Report guides

How to use the monthly reports you receive from Priority Health

Financial Summary Guide
Use this monthly report to gauge how closely your actual claims experience matches what was projected at the start of the plan year.

Network Performance and Benefit Design Summary Guide
Use this monthly report to gauge operational and provider network performance as well as utilization patterns.

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Instructions for completing and submitting PDF forms

To submit a form:
STEP 1: Open and print the form you need (requires free Adobe Acrobat Reader)
STEP 2: Complete and sign it.
STEP 3: Mail or fax it to the address or fax number printed on the form.