Find the forms your office needs

No auth needed

When performed by a participating provider in an outpatient setting, these services don't require a prior auth:

  • Colonoscopy 
  • Hernia repair 
  • Tonsillectomy 
  • Adenoidectomy 
  • Cystoscopy 
  • Lithotripsy 
  • D&C 
  • Myringotomy tubes 
  • Cholecystectomy

 

Provider forms

Find general Priority Health forms for providers below.

Also see:


AIM/High-tech Radiology Issue Resolution form  - 04/2014

Appointment of Representative (Medicare) - 03/2013

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

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

Appeals forms

Behavioral health forms

Change notification forms

Claim Refund Check form  - 01/2014

CPT Code Add Request form  - 04/2014

Credentialing forms

Direct deposit and electronic funds transfer (EFT) form

DME/P&O Prior Authorization form  - 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 

OR
Choose a form first by plan name, then by the plan effective date:

Healthy Michigan Plan Health Risk Assessment Form  - 05/2014

Hearing Services Claim Form, Priority Health Hearing Out-of-Network (Medicare) - 01/2016

HIPAA forms:

Home Safety Assessment form, Medicare - 12/2015

Home Safety Assessment Summary form, Medicare - 12/2015

Medical Prior Authorization form  - 10/2015

  • 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.
  • Starting Oct. 1, 2015: Request a pre-service organization determination when a Priority Health Medicare Advantage member is seeking services that may not be covered. 

Medical Services Questionnaire  - 04/2014

Medication Reconciliation form, Medicare - 12/2015

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

Member Injury Questionnaire  - 04/2014

Modifier 22 Explanation form  - 04/2014

Non-coverage notification forms:

PCP patient discharge/transfer of records form - 03/2016

PCP patient reassignment within a practice spreadsheet - 12/2014

Prenatal Class billing form - 05/2014

Specialty pharmacy fax forms:

Unlisted code explanation form  - 08/2015

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

Well child exam forms

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Last modified: 6/24/2016
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