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Authorization Forms
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Provider Forms
Find general Priority Health forms for providers below.
On other pages in this section you'll find:
Authorization/medical necessity forms for drugs
Authorization forms for services and devices
FDA Medwatch
forms for reporting adverse drug reactions
Medicare payer
sheets
Specialty pharmacy injectable drug request
fax forms
AIM Imaging RQI Number Request fax form
(38KB PDF)
Appointment Of Representative
(
Priority
Medicare) (55KB PDF) - Updated 11/2008
Authorization Guidelines
(
Priority
Medicare) (17KB PDF) - Updated 03/2006
Behavioral Health / PCP Coordination of Care
(407KB PDF) - Updated 11/2006
Claim Refund Check form
(152KB PDF)
CPT Code Add Request form
(31KB PDF) - Updated 12/2007
Direct Deposit/Electronic Funds Transfer (EFT) Agreement
(133KB PDF)
Domestic Violence Screening Questions & Documentation
(228KB PDF)
Electronic Claim Registration Form
(33K PDF) - Updated 08/2007
Filemart Report Request
(16KB PDF) - Updated 06/2006
Group Therapy Request
(16KB PDF) (Behavioral Health provider use only) - Updated 04/2007
Health
byChoice Incentives
forms:
Paper Qualification Form
(68KB PDF) - Updated 07/2007
Online Qualification Form
HIPAA Authorization
(33KB PDF) - Updated 10/2006
HIPAA Authorization, Spanish
(34KB PDF) - Updated 10/2006
HIPAA Revocation of Authorization
(32KB PDF) - Updated 10/2006
HIPAA Revocation of Authorization, Spanish
(30KB PDF) - Updated 10/2006
Home Health Care Services discharge form
(21KB PDF) - Updated 05/2008
Immunization Exception Documentation, Childhood and Adolescent
(immunization refusal waiver) (22KB PDF) - Updated 02/2008
Medical Services Coverage (9/02/2008: This form is being revised and will be replaced later in September)
Medical Services Questionnaire
(402KB PDF)
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)
Notice of Medicare Non-Coverage form
(38KB PDF) - Updated 02/2008
Patient Discharge form
(38KB PDF) - Updated 01/2007
Preliminary Provider Information form
(Behavioral Health providers only) (131KB PDF) - Updated 04/2008
Prior Authorization form, general
(32KB PDF) - Updated 09/2008
Provider Demographic Change Notification form
(515KB PDF) - Updated 08/2008
Provider Demographic Change Notification form, behavioral health providers
(117KB DOC) - Updated 10/2006
Provider Dispute Resolution Request Form
(33KB PDF) - Updated 04/2005
Referral to Non-Participating Provider
(54KB PDF) - Updated 08/2007
Well child exam forms:
Well Child Medical History form
(86KB PDF) - Updated 12/2006
Well Child 0-4 Week Exam form
(105KB PDF) - Updated 12/2006
Well Child 2 Month Exam form
(105KB PDF) - Updated 12/2006
Well Child 4 Month Exam form
(105KB PDF) - Updated 12/2006
Well Child 6 Month Exam form
(106KB PDF) - Updated 12/2006
Well Child 9 Month Exam form
(104KB PDF) - Updated 03/2007
Well Child 12 Month Exam form
(105KB PDF) - Updated 12/2006
Well Child 15 to 18 Month Exam form
(105KB PDF) - Updated 12/2006
Well Child 2 Year Exam form
(105KB PDF) - Updated 12/2006
Well Child 3 Year Exam form
(104KB PDF) - Updated 12/2006
Well Child 4 Year Exam form
(104KB PDF) - Updated 12/2006
Well Child 5 Year Exam form
(103KB PDF) - Updated 12/2006
Well Child 6 to 10 Year Exam form
(103KB PDF) - Updated 12/2006
Well Child 11 to 14 Year Exam form
(103KB PDF) - Updated 12/2006
Well Child 15 to 20 Year Exam form
(105KB PDF) - Updated 12/2006
Last modified
11/28/08
