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.

• Medicare Declaration of Prior Prescription Drug Coverage form
• Change PCP form*
• Change of status or plan form*
• MyPriority change of status or plan form*
• Member reimbursement form*
• Member reimbursement form, out-of-country health care expenses*
• Medicare member medical expense reimbursement form
• Medicare Part D Prescription Drug Claim form*
• Medicare reimbursement form, out-of-country health care expenses*
• Medicaid mileage reimbursement form
• Medicaid mileage reimbursement form, Spanish
• HIPAA Authorization form*
• HIPAA Authorization form, Spanish*
• Revocation of HIPAA Authorization form*
• Revocation of HIPAA Authorization form, Spanish*
• Notice of MLR rebate status

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