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 Declaration of Prior Prescription Drug Coverage form (LEP form)
- *Enroll in automatic bill payment
Sign up to have your Medicare plan premiums automatically deducted from your bank account. - *Appointment of Representative form available on the Centers for Medicare & Medicaid Services (CMS) website
Name someone who can act for you for Medicare plan enrollment, claims and grievances. - *Express Scripts home delivery order form
Use this form to order prescriptions by mail. - *Medicare appeal form
Appeal a coverage decision using this form.
Learn about the Medicare appeals process.
Medicare reimbursement request forms
- *Medical expense reimbursement request form
- *Prescription expense reimbursement request form
- *Prescription expense reimbursement request form, Spanish
- *Request for reimbursement for out-of-country expenses
- Delta Dental services claim form
- Hearing services claim form
- Out of network vision services claim form, Priority Health Vision
- Medicare Advantage disenrollment form
Use this form if you are eligible to disenroll from our Medicare Advantage plan. - Enhanced Dental and Vision package disenrollment form
Use this form if you are eligible to disenroll from our optional Enhanced Dental and Vision package. - Request a drug that is not on the formulary on the CMS website
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 31 days of the change.
Enroll in or change your FSA
- *Flexible Spending Account (FSA) enrollment/change form
To enroll when your employer provides PriorityFSASM flexible spending account benefits, or to change your payroll deductions.
Enroll in or change from automatic bill payment
- *Medicare plan members automatic bill payment enrollment form
Sign up to have your Medicare plan premiums automatically deducted from your bank account. - MyPriority plan members automatic bill payment change Form
Sign up to have your MyPriority plan premiums automatically deducted from your bank account, or to change from automatic deductions to paying your bills by mail.
Order prescriptions delivered to your home
- *Express Scripts home delivery order form
Have your prescriptions delivered through mail order.
Submit a claim for us to reimburse you
- *Member reimbursement form
Ask us to pay you back for health care or medications you purchased that your plan should cover. - Member reimbursement form, out-of-country expenses
- PriorityVision/EyeMed out-of-network vision services claim form
- *Delta Dental claim form
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
- *Health Savings Account (HSA) member deductible credit request form
Allows members who met part of their current year deductible with a previous health plan to be credited for that amount by Priority Health. - *Deductible credit request form
Allows members with a non-calendar-year deductible plan to request credit towards their deductible. - *Calendar year deductible credit request form
Allows members on a calendar-year-deductible plan (deductible renews on Jan. 1) to request credit towards their 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.