Completing PDF forms

Interactive forms (marked*)

  • Open the form.
  • Type your information.
  • Send it to Priority Health:
    Email - Click "File > Email." Use the email address listed.
    or
    Fax - Print and fax to the number listed.
  • Keep a copy. If you have:
    Adobe Reader - Print it. 
    Adobe Acrobat Standard® or Pro® - Click "File > Save as" to save the completed form.

(Check your version of Adobe: Open the program & look in the top left corner of your screen.)

Regular forms

  • Open and print the form.
  • Complete it.
  • Send it to Priority Health:
    Fax it to the number listed
    or
    Scan and email it to the email address listed.

You'll need a recent version of Adobe® Reader software to view and print PDF files. Download it free now! 

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Member 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 these form categories:

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

You'll need a recent version of Adobe® Reader software to view and print PDF files. Download it free now! 

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Medicare plan member forms
pdf *Enroll in automatic bill payment (37KB PDF) Updated 11/2013
Sign up to have your Medicare plan premiums automatically deducted from your bank account.
pdf *Appointment of Representative form (115KB PDF) Updated 06/2012
Appoint someone to act for you for Medicare plan enrollment, claims and grievances.
pdf *Medicare Appeal Form (92KB PDF)
Appeal a coverage decision using this form. Learn about the Medicare appeals process.
pdf *Ask for reimbursement (138KB PDF) Updated 8/2010
When you spend money for services that your Medicare plan should cover
*Ask for reimbursement for out-of-country expenses (288KB PDF) Updated 01/2013
pdf Request a drug that is not on the formulary (31KB PDF) 
This form is on the website of the Centers for Medicare and Medicaid Services (CMS).
pdf Medicare Advantage Disenrollment form (139KB PDF)
Use this form if you are eligible to disenroll from our Medicare Advantage plan.
MyPriority plan member forms
pdf MyPriority change of status form (122KB PDF) Updated 03/2014
Make changes to your MyPriority individual plan coverage.
Enroll in or change coverage
pdf *Change PCP form (692KB PDF) Updated 04/2014
To change your primary care physician
pdf *Change of status form (157KB PDF) - Updated 06/2014
To make changes to your name, contact information or dependent status. File within 31 days of the change.
pdf *Flexible Spending Account (FSA) Enrollment/Change form (135KB PDF) - Updated 11/2010
To enroll when your employer provides PriorityFSASM flexible spending account benefits, or to change your payroll deductions.
Enroll in /change from automatic bill payment
pdf *Medicare plan members Automatic Bill Payment Enrollment form (37KB PDF) Updated 06/2010
Sign up to have your Medicare plan premiums automatically deducted from your bank account.
pdf MyPrioritySM plan members Automatic Bill Payment Change Form (55KB PDF) Updated 03/2012
Sign up to have your MyPriority plan premiums automatically deducted from your bank account, or to change from automatic deductions to paying your bills by mail.
Submit a claim
pdf *Member reimbursement form (130KB PDF) - Updated 01/2014
*Member reimbursement form, out-of-country expenses (215KB PDF) - Updated 06/2012
pdf *Medicare Member Reimbursement form (Medicare members only) (138KB PDF) - Updated 12/2009

pdf

PriorityVision/EyeMed out-of-network vision services claim form (76KB PDF) - Updated 01/2014
Get reimbursed for out-of-network vision services.
pdf *Dental Claim form (514KB PDF) - Updated 05/2009
pdf Disability claim form (166KB PDF) - Updated 01/2013
To apply for short-term disability (STD) benefits, if your employer offers Priority Health STD services.
pdf *Disability coverage extension request form (129KB PDF) - Updated 01/2013
To be completed within three business days from the date of your last approved leave period or by the filing deadline outlined in your employer's short-term disability plan, whichever is later. Requests filed after the deadline may be denied. 
Request credit against your deductible
pdf
*Health Savings Account (HSA) Member Deductible Credit Request form (91KB PDF) - Updated 11/2011
Allows members who met part of their current year deductible with a previous health plan to be credited for that amount by Priority Health.
pdf *Deductible Credit Request form (495KB PDF) - Updated 02/2010
Flexible spending account (FSA) withdrawal requests
pdf
*Flexible Spending Account (FSA) Withdrawal Request form (194KB PDF) - Updated 11/2010
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.
pdf *Limited Flexible Spending Account (FSA) Withdrawal Request form (235KB 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
pdf *HIPAA Authorization form (174KB PDF) - Updated 06/2013
pdf *HIPAA Authorization form, Spanish (172KB PDF) - Updated 06/2013
pdf *Revocation of HIPAA Authorization form (166KB PDF) - Updated 06/2013
pdf *Revocation of HIPAA Authorization form, Spanish (124KB PDF) - Updated 06/2013
Print a HealthbyChoice (HbC) qualification form

!

Check your ID card to be sure you're choosing your HbC plan!
2014 - for plans with an effective date of 01/01/2014 or after
pdf HbC Incentives form (93KB PDF) - Updated 01/2014
pdf HbC Motivations form (92KB PDF) - Updated 11/2013
pdf HbC Progressions form (116KB PDF) - Updated 03/2014
pdf Oakland University ONLY HbC Achievements form (177KB PDF) - Updated 03/2014
2013 - for plans with 2013 effective dates 
pdf HbC Achievements form (141KB PDF) - Updated 06/2013
pdf HbC Incentives form (99KB PDF) - Updated 04/2013
pdf HbC Motivations form (137KB PDF) - Updated 06/2013
pdf HbC Progressions form (147KB PDF) - Updated 06/2013
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.
Get medical services
Forms for requesting medical services
pdf Diabetes Retinopathy Evaluation form (61KB PDF) - Updated 04/2009
   Healthy Michigan Plan Health Risk Assessment Form (697KB DOCX) - Added 4/1/2014
Last modified: 6/26/2014
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