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Health Plan Forms
Here are the most commonly used Priority Health forms. Jump down to:

Instructions for using these 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.

File a grievance

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

Enroll in or change coverage

Change PCP form (322KB PDF) Updated 03/2009
To change your primary care physician

Enrollment form (353KB PDF) - Updated 09/2009

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.

Flexible Spending Account (FSA) Enrollment/Change form (100KB PDF) - Updated 12/2009
To enroll when your employer provides PriorityFSASM flexible spending account benefits, or to change your payroll deductions.

Submit a claim

Claim form (100KB PDF) - Updated 04/2008

Member Reimbursement form (62KB PDF) - Updated 01/2007

Medicare Member Reimbursement form (Medicare members only) (87KB PDF) - Updated 02/2008

Dental Claim form (68KB PDF) - Updated 05/2009

Disability claim form (428KB PDF) - Updated 11/2009
To apply for short-term disability (STD) benefits, if your employer offers Priority Health STD services.

Withdraw or request reimbursement from a health account

Deductible Credit Request form (74KB PDF) - Updated 09/2008

Flexible Spending Account (FSA) Withdrawal Request form (154KB PDF) - Updated 01/2010
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.

Health Savings Account (HSA) Member Deductible Credit Request form (115KB PDF) - Updated 12/2009
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.

Limited Flexible Spending Account (FSA) Withdrawal Request form (141KB PDF) - Updated 01/2010
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

HIPAA Authorization form (33KB PDF) - Updated 10/2006

HIPAA Authorization form, Spanish (34KB PDF) - Updated 10/2006

Revocation of HIPAA Authorization form (28KB PDF) - Updated 10/2006

Revocation of HIPAA Authorization form, Spanish (31KB PDF) - Updated 10/2006

Use mail order pharmacy service

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.

Walgreens Mail Service Fax Order form (60KB PDF)

Walgreens Mail Service Registration and Fax Order form (123KB PDF)

Receive medical services

Diabetes Retinopathy Evaluation form (61KB PDF) - Updated 04/2009

HealthbyChoice Incentives qualification form (68KB PDF) - Updated 07/2007


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Last modified 01/28/10