Member forms

Forms marked * are interactive, so you can type information right into them. You may also be able to save the completed forms to your computer. See instructions on the left.

Click on these categories to see available forms:

Medicare plan member forms

Reimbursement request forms for Medicare members:

Change your name, address, dependents, PCP or plan

  • *Change PCP form
    To change your primary care physician, it's faster to log in to your account and click Change my doctor." Or, use these other options.
  • *Change of status or plan form
    To make changes to your name, marital status and contact information, or add or remove dependents. File within 31 days of the change.
  • *MyPriority change of status or plan form
    To make changes to your name, marital status and contact information, or add or remove dependents. File within 31 days of the change.

Enroll in or change your FSA

Enroll in or change from automatic bill payment

Order prescriptions delivered to your home

Submit a claim for us to reimburse you

Request credit against your deductible

Give or remove permission to see your personal information (HIPAA authorization)

Print a HealthbyChoice (HbC) qualifications form

Careful! Choose by plan name (check your membership card).

File a complaint

Learn about the steps to follow and get the forms to file a complaint, or "grievance," with Priority Health.

  • Go to the regular grievance process
  • Go to the Medicare grievance process
  • Go to the FEHB grievance process
  • Get medical services

    Forms for requesting medical services

    Healthy Michigan Plan Health Risk Assessment Form (English, Spanish, and Arabic)