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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 (3.0MB PDF) Updated 06/2010
To change your primary care physician

Enrollment form (763KB PDF) - Updated 06/2010

Change of Status form (514KB PDF) - Updated 06/2010
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 (531KB PDF) - Updated 06/2010
To enroll when your employer provides PriorityFSASM flexible spending account benefits, or to change your payroll deductions.

Submit a claim

Member Reimbursement form (470KB PDF) - Updated 04/2010

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

Dental Claim form (514KB PDF) - Updated 05/2010

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

Health Savings Account (HSA) Member Deductible Credit Request form (179KB PDF) - Updated 04/2010
Allows members who met part of their current year deductible with a previous health plan to be credited for that amount by Priority Health.

Deductible Credit Request form (495KB PDF) - Updated 02/2010


Request flexible spending account (FSA) withdrawals

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.

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

HIPAA Authorization form (57B PDF) - Updated 05/2010

HIPAA Authorization form, Spanish (98KB PDF) - Updated 05/2010

Revocation of HIPAA Authorization form (61KB PDF) - Updated 05/2010

Revocation of HIPAA Authorization form, Spanish (57KB PDF) - Updated 05/2010

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 (99KB PDF) - Updated 02/2010


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Last modified 06/07/10