Employer forms

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 right.

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Employer forms
Forms to be filled out by your company's benefits administrator
Web page Request to Access Employer Online Tools (online form for agents)
Agents can use this form to request permission from you and Priority Health to access your online information.
pdf *Group Automatic Bill Payment Plan Enrollment - fully-funded (916KB PDF)
Sign up to have your monthly premium automatically withdrawn from your checking account.
pdf *Group Automatic Premium/Weekly Funding ACH/EFT Payment Plan Enrollment/Change - self-funded (72KB PDF) - Updated 06/2014
Sign up to have your monthly premium/weekly funding ACH/EFT automatically withdrawn from your checking/savings account.
pdf *Large group application form (456KB PDF) - Updated 02/2015 (Log-in required)
For employer groups with 51+ eligible employees who are applying for Priority Health coverage. The group agreement is included with this form.
Excel Large group new enrollment spreadsheet (1MB XLS) - Updated 03/2015 (Log-in required)
For new groups with 51+ eligible employees only. Enter group enrollment information in this spreadsheet and send it to your agent. Use this only if your agent asked for it.
pdf *Medicare Part D - MAPD employer group agreement (34KB PDF) - Updated 01/2014 (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.
pdf *PriorityFSA Adoption Agreement (164KB PDF) - Updated 11/2014
To be filled out by an employer group that has PriorityFSA
pdf *PriorityFSA Application - Large Business Group (352KB PDF) - Updated 11/2014
pdf *Request for Supplies form (60KB PDF) - Updated 12/2013
Word document Sample Summary Plan Description (SPD "Wrap") instructions and template (975KB DOC) - Updated 01/2014
pdf *Small group proposal request form (119KB PDF) - Updated 03/2014
Groups with 1-50 eligible employees can complete this form to request a quote for coverage.
pdf *Small group termination form (99KB PDF) - Updated 01/2014
Groups with 1-50 eligible employees can use this form to give Priority Health 30 days' notice of their group coverage termination. 
Enrollment/change forms
To be filled out by your employees when they enroll in or change their coverage.
pdf *Change PCP (692KB PDF) - Updated 01/2014
For a member to change his/her primary care physician (PCP)
pdf *Change of status form (157KB PDF) - Updated 06/2014
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, or complete the Medicare Disenrollment Form, below
pdf *Employee Coverage Waiver (33KB PDF) - Updated 02/2012
Have employees fill this out when they want to waive Priority Health coverage.
pdf *Enrollment form (333KB PDF) - Updated 09/2014
pdf *Flexible spending account (FSA) enrollment/change (139KB PDF) - Updated 01/2014
To enroll in or make changes to FSA benefits under a 125 plan.
pdf Medicare plan group MAPD disenrollment form (138KB PDF) - Updated 01/2014
pdf Medicare plan group PDP disenrollment form (131KB PDF) - Updated 01/2014
pdf *PriorityDental and PriorityVision member enrollment form (770KB PDF) - Updated 11/2012
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.
pdf Attending physician statement (102KB PDF) - Updated 01/2014
To be completed by employee's physician when employee is applying for short-term disability (STD) benefits. To be used only by employer groups/employees for whom Priority Health provides STD services.
pdf *Disability claim form (166KB PDF) - Updated 01/2013
To be completed when an employee is applying for short-term disability (STD) benefits you offer through Priority Health.
pdf *Disability coverage extension request form (129KB PDF) - Updated 01/2013
To be completed within three business days from the date of employee's last approved leave period or by the filing deadline outlined in your short-term disability plan, whichever is later. Requests filed after the deadline may be denied. 
pdf *Flexible spending account (FSA) withdrawal request (194KB PDF) - Updated 11/2010
To request withdrawals from FSA accounts (medical and dependent care).
pdf HealthbyChoice qualification forms:
pdf *HIPAA authorization (323KB PDF) - Updated 02/2012
pdf *HIPAA authorization, Spanish (332KB PDF) - Updated 02/2012
pdf *HSA member deductible credit request form (91KB PDF) - Updated 11/2011
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.
pdf *Limited FSA withdrawal request form for HSA (169KB PDF) - Updated 12/2012
pdf *Member reimbursement form (470KB PDF) - Updated 01/2014
pdf PriorityVision/EyeMed out-of-network vision services claim form (76KB PDF) - Updated 01/2014
For a member to get reimbursed for out-of-network vision services.
pdf *Revocation of HIPAA authorization (99KB PDF) - Updated 05/2010
pdf *Revocation of HIPAA authorization, Spanish (37KB PDF) - Updated 05/2010
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.

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Last modified: 4/2/2015
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