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 (LEP 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
- Medicaid member instructions for digital mileage reimbursement form
- 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.
Can’t find what you’re looking for?
The larger list of forms is located within the Member Center.