Member forms

Forms marked * are interactive, so you can type information right into them. Follow the instructions on the form to find out where to send it once you've completed filling it out.

If you have questions, contact our customer service team by calling the number on the back of your membership card.

Choose from these categories to see available forms.

Medicare member forms

Medicare reimbursement request forms

Change your PCP, name, address, dependents or plan

It's faster to change your PCP online. Log in to your member account and choose My health care, then Find a Doctor.

  • *Change of status or plan form
    Use this 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
    Use this form to make changes to your name, marital status and contact information, or add or remove dependents. File within 60 days of the change.

Enroll in or change your FSA

Enroll in or change from automatic bill payment

Submit a claim for us to reimburse you

You can request an out-of-network claim form be mailed to you by calling the EyeMed Customer Service Department at 844.366.5127, Monday through Friday 8 a.m. to 8 p.m. EST (TTY users should call 711).

Medicaid

You can also log in to your member account to complete and submit a digital version of this form.

Request credit against your deductible

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

Print a HealthbyChoice (HbC) qualifications form

Check your membership card and choose by plan name. 

File a complaint or an appeal

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

Get medical services

Healthy Michigan Plan Health Risk Assessment form (English, Spanish, and Arabic) from the Michigan Department of Health & Human Services

Nonopioid directive form

This form permits a member to direct their Primary Care Physician (PCP) to avoid prescribing opioids to treat pain.

Inclusivity resources

Communication impediment designation form

This form is for drivers and/or occupants in a vehicle who are deaf, hearing-impaired, or autistic. You can request a special "communication impediment" designation be placed on your Secretary of State record to notify law enforcement about your and/or your occupants specific communication needs. The designation is voluntary and is not printed on your driver's license, state ID care, or vehicle registration.