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
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)

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)

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Enrollment/change forms

To be filled out by your employees when they enroll in or change their coverage

ASO 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

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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 (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

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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.