Provider forms
Find general Priority Health forms for providers below.
Or go to:
AIM Imaging Authorization Request fax form (38KB PDF)
Appointment of Representative (Priority Health Medicare) (55KB PDF) - Updated 11/2008
Appeals forms
Behavioral Health / Midlevel Practitioner Enrollment Form (107KB PDF) - Can be filled out online and printed. Updated 11/2011
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) forms
Both forms need to be submitted to set up electronic claim payments.
DME / P&O Prior Authorization form (474KB PDF) - New 12/2010
Complete online and save it for your records, then print and fax it to Priority Health.
Electronic Claim Registration form (33KB PDF) - Updated 08/2007
HealthbyChoice qualification forms:
HIPAA forms
Home Health Care Services Discharge form (21KB PDF) - Updated 09/2010
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
You must be logged in to access this form.
MSU Non-Contracted Specialty Access Form (32 KB PDF) - Added 2/2011
For referrals of Medicaid members to MSU specialists
Medical Prior Authorization form (522KB PDF) – New 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 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
Non-adherent member exclusion form (63KB PDF) - Updated 09/2010
You must be logged in to access this form.
Non-participating Provider Change form (67KB PDF) - Added 05/2010
Notice of Medicare Non-Coverage form (478KB PDF) - Updated 03/2011
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 08/2011
Preliminary Provider Information form (Behavioral Health providers only) (131KB PDF) - Updated 05/2011
Prenatal Class (Healthy Encounters Maternity) billing form (54KB PDF) - Updated 06/2010
Prior Authorization form, general
Replaced with the Medical Prior Authorization form (522KB PDF) – New 12/2010
Complete online and save it for your records, then print and fax it to Priority Health.
Provider Demographic Change Notification form (180KB PDF) - Updated 12/2011
Provider Dispute Resolution Request Form - See Appeals forms, above
Referral to Non-Participating Provider
Replaced with the Medical Prior Authorization form (522KB PDF) – New 12/2010
Complete online and save it for your records, then print and fax it to Priority Health.
Specialty pharmacy fax forms
Well child exam forms
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