Skip to content Priority Health
Sections

Provider Forms

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 (PriorityMedicare) (55KB PDF) - Updated 11/2008

Behavioral Health / PCP Coordination of Care (407KB PDF) - Can be filled out online and printed. Updated 03/2009

Claim Refund Check form (152KB PDF)

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

Credentialing application forms for organizational providers:

Direct Deposit/Electronic Funds Transfer (EFT) Agreement (115KB PDF)

Domestic Violence Screening Questions & Documentation (228KB PDF)

Electronic Claim Registration Form (33K PDF) - Updated 08/2007

HealthbyChoice Incentives forms:

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 (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 (402KB PDF)

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 (25KB PDF) - Updated 11/2008

Notice of Medicare Non-Coverage form (775KB PDF) - Updated 02/2008
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 Expectations) billing form (59KB PDF) - Updated 05/2009

Prior Authorization form, general (32KB PDF) - Updated 09/2008

Provider Demographic Change Notification form (515KB PDF) - Updated 11/2009

Provider Dispute Resolution Request Form (33KB PDF) - Updated 03/2009

Referral to Non-Participating Provider (31KB PDF) - Updated 08/2007

Well child exam forms:
Last modified 11/20/09