Health Plan Forms

Here are the most commonly used Priority Health forms.

To submit a form:
STEP 1: Open and print the form you need (requires free Adobe Acrobat Reader)
STEP 2: Complete and sign it.
STEP 3: Mail or fax it to the address or fax number printed on the form.

Change PCP form (29KB PDF)
To change your Primary Care Physician

Change of Status form (44KB PDF)
To make changes to your name, contact information or dependent status. File within 31 days of the change.

Claim form (74KB PDF)

Deductible Credit Request form (74KB PDF)

Dental Claim form (68KB PDF)

Disability Claim form (932KB PDF)
To apply for short-term disability (STD) benefits, if your employer offers Priority Health STD services.

Flexible Spending Account (FSA) Enrollment/Change form (198KB PDF)
To enroll for FSA benefits under a 125 plan, when your employer provides Priority Health FSA benefits.

Flexible Spending Account (FSA) Withdrawal Request form (54KB PDF)
To request withdrawals from FSA account (medical, dependent care, adoption assistance). If you have an HSA, use the Limited Flexible Spending Account Withdrawal Request form, below.

Grievance form
To file a grievance, fill out and submit this online form.

HealthbyChoice Incentives Qualification form (68KB PDF)

HIPAA Authorization form (33KB PDF)

HIPAA Authorization form, Spanish (34KB PDF)

Health Reimbursement Account (HRA) Withdrawal Request form (56KB PDF)

Limited Flexible Spending Account (FSA) Withdrawal Request form (33KB PDF)
For use to request withdrawals from your Flexible Spending Account when you also have a Health Savings Account.

Member Reimbursement form (62KB PDF)

Member Reimbursement form (PriorityMedicare members only) (87KB PDF)

Retinopathy Evaluation form (31KB PDF)

Revocation of HIPAA Authorization form (28KB PDF)

Revocation of HIPAA Authorization form, Spanish (31KB PDF)

Walgreens Mail Service Registration & Prescription Order form (300KB PDF)

Walgreens Healthcare Plus Fax Order form (300KB PDF)


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