|
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 Instructions for submitting PDF forms Employer formsForms to be filled out by your company's benefits administratorRequest 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) Large Group Application (125KB PDF) - Updated 08/2007 (Must be logged in to view.) For employer groups with 50+ eligible employees who are applying for Priority Health coverage. Request for Supplies (32KB PDF) - Updated 06/2008 East region Small Group Application (136KB PDF) - Updated 06/2008 (Must be logged in to view.) 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 (547KB PDF) - Updated 03/2008 (Must be logged in to view.) 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. SPD "Wrap" Instructions and Template (80KB PDF; text available to cut and paste) SPD "Wrap" Instructions and Template (137KB DOC) Enrollment/change formsTo be filled out by your employees when they enroll in or change their coverageASO Change/Election (36KB PDF) Change PCP (29KB PDF) Change of Status form (44KB PDF) - Updated 03/2005 To make changes to and employee's name, contact information or dependent status. Enrollment Form (387KB PDF) - Updated 08/2008 Flexible Spending Account (FSA) Enrollment/Change (505KB PDF) - Updated 08/2008 To enroll in or make changes to FSA benefits under a 125 plan. PPO/Indemnity Change of Status (268KB PDF) - Updated 03/2001 Claim, physician, reimbursement and other formsTo be filled out by employees when they need to visit their physicians, request services or give authorization for serviceAttending Physician Statement (113KB PDF) - Updated 05/2005 To be completed by a physician when applying for short-term disability (STD) benefits covered by Priority Health. Claim Form (74KB PDF) - Updated 01/2007 Disability Claim (428KB PDF) - Updated 05/2005 To be completed when an employee is applying for short-term disability (STD) benefits you offer through Priority Health. Employee Waiver (80KB PDF) Flexible Spending Account (FSA) Withdrawal Request (120KB PDF) - Updated 04/2006 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 Member Reimbursement form (62KB PDF) - Updated 01/2007 Revocation of HIPAA Authorization (32KB PDF) - Updated 10/2006 Walgreens Mail Service Registration & Prescription Order (56KB PDF) - Updated 02/2005 Walgreens Mail Service Fax Order (51KB PDF) - Updated 03/2005 Instructions for completing and submitting PDF formsTo 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.
Last modified
08/28/08
|
