Employer Forms
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| Forms to be filled out by your company's benefits administrator |
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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. |
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*Group Automatic Bill Payment Plan Enrollment (399KB PDF)
Sign up to have your monthly premium automatically withdrawn from your checking account. |
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*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. |
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*Request for Supplies form (60KB PDF) - Updated 08/2010 |
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*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. |
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*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. |
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PriorityFSA Adoption Agreement (77KB PDF) - Updated 11/2008
To be filled out by an employer group that has PriorityFSA |
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*PriorityFSA Application - Small Business Group (55KB PDF) - Updated 02/2009 |
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*PriorityFSA Application - Large Business Group (330KB PDF) - Updated 04/2010 |
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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.
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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
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| To be filled out by your employees when they enroll in or change their coverage. |
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*Change PCP (3.0MB PDF) - Updated 06/2010
For a member to change his/her primary care physician (PCP) |
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*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 |
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*Employee Coverage Waiver (186KB PDF) - Updated 06/2010
Have employees fill this out when they want to waive Priority Health coverage. |
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*Enrollment form (763KB PDF) - Updated 06/2010 |
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*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. |
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*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. |
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*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. |
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*Flexible Spending Account (FSA) Withdrawal Request (1169KB PDF) - Updated 02/2010
To request withdrawals from FSA accounts (medical and dependent care). |
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HealthbyChoice Incentives Qualification Form (99KB PDF) - Updated 02/2010 |
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*HIPAA Authorization (53KB PDF) - Updated 05/2010 |
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*HIPAA Authorization, Spanish (98KB PDF) - Updated 05/2010 |
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*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. |
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*Limited FSA Withdrawal Request form for HSA (157KB PDF) - Updated 02/2010 |
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*Member Reimbursement form (470KB PDF) - Updated 04/2010 |
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*Revocation of HIPAA Authorization (61KB PDF) - Updated 05/2010 |
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*Revocation of HIPAA Authorization, Spanish (57KB PDF) - Updated 05/2010 |
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Walgreens Mail Service Registration & Prescription Order (56KB PDF) - Updated 02/200 |
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Walgreens Mail Service Fax Order form (51KB PDF) - Updated 03/2005 |
Report Guides
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| How to use the monthly reports you receive from Priority Health. |
Web page
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*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
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*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. |