| Medicare plan member forms |
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*Enroll in automatic bill payment (37KB PDF) Updated 06/2010
Sign up to have your Medicare plan premiums automatically deducted from your bank account. |
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*Appointment of Representative form (115KB PDF) Updated 12/2009
Appoint someone to act for you for Medicare plan enrollment, claims and grievances.
Form number H2320_3000_3005_3 F&U (12/2009), H4875_3000_3005_3 F&U (12/2009), S5857_3000_3005_3 F&U (12/2009) |
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*Medicare Appeal Form (92KB PDF)
File a complaint, called a "grievance," when you're a member of a Priority Health Medicare plan. |
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*Ask for reimbursement (138KB PDF) Updated 8/2010
When you spend money for services that your Medicare plan should cover |
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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). |
| Enroll in or change coverage |
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*Change PCP form (1.6MB PDF) Updated 06/2010
To change your primary care physician |
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*Change of Status form (925KB PDF) - Updated 12/2010
To make changes to your name, contact information or dependent status. File within 31 days of the change. |
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*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 |
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*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. |
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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 |
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*Member reimbursement form (470KB PDF) - Updated 04/2010 |
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*Medicare Member Reimbursement form (Medicare members only) (138KB PDF) - Updated 12/2009 |
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*Dental Claim form (514KB PDF) - Updated 05/2009 |
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*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
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*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. |
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*Deductible Credit Request form (495KB PDF) - Updated 02/2010 |
| Flexible spending account (FSA) withdrawal requests |
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*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. |
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*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 |
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*HIPAA Authorization form (323KB PDF) - Updated 02/2012 |
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*HIPAA Authorization form, Spanish (332KB PDF) - Updated 02/2012 |
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*Revocation of HIPAA Authorization form (99KB PDF) - Updated 11/2010 |
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*Revocation of HIPAA Authorization form, Spanish (36KB PDF) - Updated 11/2010 |
| Print a HealthbyChoice (HbC) qualification form |
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Check your ID card to be sure you're choosing your HbC plan! |
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HbC Achievements form (301KB PDF) - Updated 02/2012 |
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HbC Incentives form (99KB PDF) - Updated 11/2011 |
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HbC Motivations form (267KB PDF) - Updated 02/2012 |
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HbC Progressions form (322KB PDF) - Updated 02/2012 |
| File a grievance |
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| Learn about the steps to follow to file a complaint, or "grievance," with Priority Health. |
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Grievance form
To file a grievance, fill out and submit this secure online form. |
| Get medical services |
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| Forms for requesting medical services |
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Diabetes Retinopathy Evaluation form (61KB PDF) - Updated 04/2009 |
* 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!
