Member forms

Forms labeled "Interactive" allow you to type information right into them. Follow the instructions on each form for how to fill out and submit your form. 

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

Most used forms

request reimbursement form

Request reimbursement for a medical expense your plan should cover

Interactive form

For Medicare plans

For MyPriority, Medicaid and Group plans

HIPAA form image

Give or remove permission to see your personal information

Interactive form

For all plans

All forms

Medicare member forms

Enroll in automatic bill payment

Sign up to have your Medicare plan premiums automatically deducted from your bank account or credit card by logging into your member account and clicking Billing and Set up/manage automatic payments.

Login to enroll online

Prefer to print or email your form? Use the form below.

Medicare reimbursement request forms

Change your PCP, name, address, dependents or plan

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

  • Change PCP form - Interactive form
  • Change of status or plan form - Interactive 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 information change form - Interactive 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.

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

Request reimbursement for a medical expense

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.

Automatic bill payment enrollment or change

Enroll in automatic bill payment

Sign up to have your plan premiums automatically deducted from your bank account or credit card by logging into your member account and clicking Billing and Set up/manage automatic payments.

Login to enroll online

Prefer to print or email your form? Use the forms below.  

Request credit against your deductible

Flexible Spending Account (FSA) enrollment or change

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.

Health Risk Assessment

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.

Deaf, hearing impaired, or autism resources

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.