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Instructions for completing online forms
Interactive forms
(marked *)
  1. Open the form you need (requires free Adobe® Reader® software).
  2. Type in your information.
  3. E-mail it to Priority Health by clicking "File > Email" and sending it to the e-mail address printed on the form. Or fax a printed copy to the number listed on the form.
  4. Keep a copy for your records. If you have Adobe Reader, print a copy. If you have Adobe Acrobat Standard® or Pro®, you can click "File > Save as," and save the completed form to your computer.
(To check your version of Adobe, look in the top left corner of your screen when the program is open.)

Regular forms
  1. Open and print the form you need (requires free Adobe® Reader® software).
  2. Complete it.
  3. Fax it to the fax number printed on the form or scan it and e-mail it to the e-mail address printed on the form.

Forms list

Here are the most commonly used Priority Health forms. 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 left.

Jump down to:

File a grievance
Learn about the steps to follow to file a complaint, or "grievance," with Priority Health.
Web page
Web page
Grievance form
To file a grievance, fill out and submit this secure online form.
Enroll in or change coverage
Adobe PDF File *Change PCP form (322KB PDF) Updated 03/2009
To change your primary care physician
Adobe PDF File *Enrollment form (353KB PDF) - Updated 09/2009
Adobe PDF File *Change of Status form (471KB PDF) - Updated 03/2009
To make changes to your name, contact information or dependent status. File within 31 days of the change.
Adobe PDF File *Flexible Spending Account (FSA) Enrollment/Change form (139KB PDF) - Updated 02/2010
To enroll when your employer provides PriorityFSASM flexible spending account benefits, or to change your payroll deductions.
Submit a claim
Adobe PDF File *Member Reimbursement form (62KB PDF) - Updated 01/2007
Adobe PDF File *Medicare Member Reimbursement form (Medicare members only) (87KB PDF) - Updated 02/2008
Adobe PDF File *Dental Claim form (68KB PDF) - Updated 05/2009
Adobe PDF File *Disability claim form (171KB PDF) - Updated 03/2010
To apply for short-term disability (STD) benefits, if your employer offers Priority Health STD services.
Request Credit against your deductible
Adobe PDF File
*Health Savings Account (HSA) Member Deductible Credit Request form (115KB PDF) - Updated 12/2009
Allows members who met part of their current year deductible with a previous health plan to be credited for that amount by Priority Health.
Adobe PDF File *Deductible Credit Request form (495KB PDF) - Updated 02/2010
Request flexible spending account (FSA) withdrawals
Adobe PDF File
*Flexible Spending Account (FSA) Withdrawal Request form (169KB PDF) - Updated 02/2010
To request withdrawals from your FSA account (medical, dependent care).
NOTE: If you have an HSA too, use the Limited Flexible Spending Account Withdrawal Request form, below.
Adobe PDF File *Limited Flexible Spending Account (FSA) Withdrawal Request form (157KB PDF) - Updated 02/2010
For use to request withdrawals from your Flexible Spending Account (FSA) when you also have a Health Savings Account (HSA).
Give or remove HIPAA authorization
Adobe PDF File *HIPAA Authorization form (33KB PDF) - Updated 10/2006
Adobe PDF File *HIPAA Authorization form, Spanish (34KB PDF) - Updated 10/2006
Adobe PDF File *Revocation of HIPAA Authorization form (28KB PDF) - Updated 10/2006
Adobe PDF File *Revocation of HIPAA Authorization form, Spanish (31KB PDF) - Updated 10/2006
Use mail order pharmacy service
Adobe PDF File Walgreens Mail Service Registration & Prescription Order form - to send in the mail (81KB PDF)
Use this form the first time you place an order for yourself or one of your dependents.
Adobe PDF File Walgreens Mail Service Registration and Order form - to send in by fax (123KB PDF)
Receive medical services
Adobe PDF File Diabetes Retinopathy Evaluation form (61KB PDF) - Updated 04/2009
Adobe PDF File HealthbyChoice Incentives qualification form (99KB PDF) - Updated 02/2010


* Indicates that the PDF can be filled in online, then saved to your computer or printed. See the instructions in the left column.

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Last modified 08/18/10