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Find general Priority Health forms for
providers below.
On other pages in this section you'll find:
AIM Imaging Authorization Request fax form (38KB PDF) Appointment of Representative (Priority Health Medicare) (55KB PDF) - Updated 11/2008 Behavioral Health / PCP Coordination of Care (407KB PDF) - Can be filled out online and printed. Updated 03/2009 Change Notification form (206KB PDF) - Updated 07/2010 Change Notification form, non-participating providers (67KB PDF) - Added 05/2010 Claim Refund Check form (152KB PDF) CPT Code Add Request form (31KB PDF) - Updated 11/2009 Credentialing application forms for organizational providers
Direct deposit and electronic funds transfer (EFT) formsBoth forms need to be submitted to set up electronic claim payments.
Domestic Violence Screening Questions & Documentation (228KB PDF) Electronic Claim Registration Form (33K PDF) - Updated 08/2007 HealthbyChoice Incentives forms:
HIPAA forms
Home Health Care Services discharge form (21KB PDF) - Updated 08/2008 Complete online and save it for your records, then print and fax it to Priority Health. Immunization Exception Documentation, Childhood (immunization refusal waiver) (16KB PDF) - Updated 12/2008 Medical Services Coverage ("waiver" or "acknowledgment" form for when services not covered): Use "Patient Acknowledgement of Financial Responsibility," below Medical Services Questionnaire (27KB PDF) - Updated with new fax number 4/2010 Mid-level Physician Extender Information form (40KB PDF) - Updated 12/2008 Modifier 22 Explanation form (17KB PDF) - Updated 08/2006 NPI Number Notification form - Individual Practitioner (Type 1) (116KB DOC) NPI Number Notification form - Group (Type 2) (115KB DOC) Non-adherent member exclusion form (63KB PDF) - Updated 09/2010 Complete online and save it for your records, then print and fax it to Priority Health. Non-participating Provider Change Form (67KB PDF) - Added 05/2010 Notice of Medicare Non-Coverage form (566KB PDF) - Updated 01/2010 Complete online and save it for your records, then print and fax it to Priority Health. Patient Acknowledgment of Financial Responsibility (103KB PDF) Updated 03/2009 Patient Discharge form (38KB PDF) - Updated 01/2007 Preliminary Provider Information form (Behavioral Health providers only) (131KB PDF) - Updated 04/2008 Prenatal Class (Healthy Encounters Maternity) billing form (54KB PDF) - Updated 06/2010 Prior Authorization form, general (515KB PDF) - Updated 12/2009 Complete online and save it for your records, then print and fax it to Priority Health. Provider Demographic Change Notification form (160KB PDF) - Updated 04/2010 Provider Dispute Resolution Request Form (89KB PDF) - Updated 06/2010 Referral to Non-Participating Provider (31KB PDF) - Updated 12/2009 Complete online and save it for your records, then print and fax it to Priority Health. Specialty pharmacy fax forms
Well child exam forms
Last modified
09/02/10
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