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Provider forms

Find general Priority Health forms for providers below.

Or go to authorization forms:


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

Appointment of Representative (Medicare)  - 03/26/2013

Appeals forms

Behavioral health forms

Change notification forms

Claim Refund Check form (152KB PDF)

CPT Code Add Request form (31KB PDF) - 11/2009

Credentialing application forms for organizational providers

Direct deposit and electronic funds transfer (EFT) form

DME / P&O Prior Authorization form (474KB PDF) - 12/2010
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)

 

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) – 12/2010
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 (27KB PDF) - 4/2010

Medicare Waiver of Liability (non-participating provider) (185KB PDF) – 06/2012
Complete online and save it for your records, then print and fax it to Priority Health.

Member Injury Questionnaire (19KB PDF) - 08/2012

Modifier 22 Explanation form (17KB PDF) - 08/2006

 

Notices of non-coverage:

 

Patient Discharge form (37KB PDF) - 11/2012

Preliminary Provider Information form (Behavioral Health providers only) (131KB PDF) - 05/2011

Prenatal Class billing form (54KB PDF) - 06/2010

Provider Supplemental Enrollment Form (74KB PDF) - 11/2013

 

Specialty pharmacy fax forms:

 

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

 

Well child exam forms

 

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    Last modified: 4/18/2014
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