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 Tools (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Sign up to have your monthly premium automatically withdrawn from your checking account.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 12/2010 (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 (515KB PDF) - Updated 04/2011 (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. Paper applications are valid for 09/01/2011 effective dates only. Use ClientManagerSM for effective dates of 10/01/2011 and after. |
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*West region small group application form (475KB PDF) - Updated 04/2011 (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. Paper applications are valid for 09/01/2011 effective dates only. Use ClientManagerSM for effective dates of 10/01/2011 and after. |
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PriorityFSA Adoption Agreement (77KB PDF) - Updated 08/2010
To be filled out by an employer group that has PriorityFSA |
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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 (23KB PDF) - Updated 03/2011 (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. |
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Sample Summary Plan Description (SPD "Wrap") instructions and template (168KB DOC) - Updated 07/2010 |
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Large group new enrollment spreadsheet (216KB XLS) - Updated 01/2011 (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.
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| 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 (1.6MB PDF) - Updated 06/2010
For a member to change his/her primary care physician (PCP) |
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*Change of status form (925KB PDF) - Updated 12/2010
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, or complete the Medicare Disenrollment Form, below |
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*Employee Coverage Waiver (33KB PDF) - Updated 02/2012
Have employees fill this out when they want to waive Priority Health coverage. |
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*Enrollment form (763KB PDF) - Updated 12/2010 |
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*Medicare Disenrollment Form (148KB PDF) - Updated 03/2011 |
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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 |
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| 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 (194KB PDF) - Updated 11/2010
To request withdrawals from FSA accounts (medical and dependent care). |
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HealthbyChoice qualification forms: |
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*HIPAA authorization (323KB PDF) - Updated 02/2012 |
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*HIPAA authorization, Spanish (332KB PDF) - Updated 02/2012 |
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*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. |
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*Limited FSA withdrawal request form for HSA (234KB PDF) - Updated 12/2010 |
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*Member reimbursement form (470KB PDF) - Updated 04/2010 |
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*Revocation of HIPAA authorization (99KB PDF) - Updated 05/2010 |
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*Revocation of HIPAA authorization, Spanish (37KB PDF) - Updated 05/2010 |
Report guides
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| How to use the monthly reports you receive from Priority Health. |
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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. |
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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. |
