Provider forms

Find general Priority Health forms for providers below.

Or go to authorization forms:


AIM/High-tech Radiology Issue Resolution form (540KB PDF) - 04/2014

Appointment of Representative (Medicare) - 03/2013

Appointment reminder card ("Make your move" replacement), black & white (314KB PDF) - 08/2014

Appointment reminder card ("Make your move" replacement), color (369KB PDF) - 08/2014

Appeals forms

Behavioral health forms

Change notification forms

Claim Refund Check form (152KB PDF) - 01/2014

CPT Code Add Request form (995KB PDF) - 04/2014

Credentialing forms

Direct deposit and electronic funds transfer (EFT) form

DME/P&O Prior Authorization form (543KB PDF) - 04/2014
Complete online and save it for your records, then print and fax it to Priority Health.

Electronic Remittance Advice Registration form

Fee schedule request form (interactive)

HealthbyChoice qualification forms:

Healthy Michigan Plan Health Risk Assessment Form (697KB DOC) - 05/2014

HIPAA forms:

MSU Non-Contracted Specialty Access Form (32 KB PDF) - 2/2011
For referrals of Medicaid members to MSU specialists

Medical Prior Authorization form (522KB PDF) - 11/2013
To request prior authorization for medical services both in and out of network, complete online and save it for your records, then print and fax it to Priority Health.

Medical Services Questionnaire (541KB PDF) - 4/2014

Medicare Waiver of Liability (non-participating provider) (191KB PDF) - 04/2014
Complete online and save it for your records, then print and fax it to Priority Health.

Member Injury Questionnaire (516KB PDF) - 04/2014

Modifier 22 Explanation form (67KB PDF) - 04/2014

Notices of non-coverage:

Patient Discharge form (37KB PDF) - 09/2013

Prenatal Class billing form (136KB PDF) - 05/2014

Provider Supplemental Enrollment Form (74KB PDF) - 08/2014

Specialty pharmacy fax forms:

W-9: Go to the IRS website for this form.

Well child exam forms

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Last modified: 10/24/2014
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