Completing PDF forms

Interactive forms (marked*)

  • Open the form.
  • Type your information.
  • Send it to Priority Health:
    Email - Click "File > Email." Use the email address listed.
    or
    Fax - Print and fax to the number listed.
  • Keep a copy. If you have:
    Adobe Reader - Print it. 
    Adobe Acrobat Standard® or Pro® - Click "File > Save as" to save the completed form.

(Check your version of Adobe: Open the program & look in the top left corner of your screen.)

Regular forms

  • Open and print the form.
  • Complete it.
  • Send it to Priority Health:
    Fax it to the number listed
    or
    Scan and email it to the email address listed.

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Member forms

Forms marked * are interactive, so you can type information right into them. You may also be able to save the completed forms to your computer. See instructions on the left.

Jump down to these form categories:

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Medicare plan member forms
pdf *Enroll in automatic bill payment (37KB PDF) Updated 11/2013
Sign up to have your Medicare plan premiums automatically deducted from your bank account.
pdf *Appointment of Representative form (115KB PDF) Updated 06/2012
Appoint someone to act for you for Medicare plan enrollment, claims and grievances.
pdf *Medicare Appeal Form (92KB PDF)
Appeal a coverage decision using this form. Learn about the Medicare appeals process.
pdf

*2014 medical or Rx expense reimbursement request form (138KB PDF) Updated 1/2015, use for expenses you paid in 2014.
*2015 medical expense reimbursement request form (51KB PDF) Added 01/2015
*2015 prescription expense reimbursement request form (270KB PDF) Added 01/2015
*Ask for reimbursement for out-of-country expenses (288KB PDF) Updated 01/2013

pdf Request a drug that is not on the formulary (31KB PDF) 
This form is on the website of the Centers for Medicare and Medicaid Services (CMS).
pdf Medicare Advantage Disenrollment form (139KB PDF)
Use this form if you are eligible to disenroll from our Medicare Advantage plan.
MyPriority plan member forms
pdf MyPriority change of status form (122KB PDF) Updated 03/2015
Make changes to your MyPriority individual plan coverage.
Enroll in or change coverage
pdf *Change PCP form (692KB PDF) Updated 04/2014
To change your primary care physician
pdf *Change of status form (157KB PDF) - Updated 06/2014
To make changes to your name, contact information or dependent status. File within 31 days of the change.
pdf *Flexible Spending Account (FSA) Enrollment/Change form (135KB PDF) - Updated 11/2010
To enroll when your employer provides PriorityFSASM flexible spending account benefits, or to change your payroll deductions.
Enroll in /change from automatic bill payment
pdf *Medicare plan members Automatic Bill Payment Enrollment form (37KB PDF) Updated 06/2010
Sign up to have your Medicare plan premiums automatically deducted from your bank account.
pdf MyPriority plan members Automatic Bill Payment Change Form (56KB PDF) Updated 02/2015
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.
Submit a claim for us to reimburse you
pdf *Member reimbursement form (130KB PDF) - Updated 01/2014
*Member reimbursement form, out-of-country expenses (215KB PDF) - Updated 06/2012
pdf *2014 Medicare Medical and Part D Drug Reimbursement form (Medicare members only, for medical and drug expenses you paid in 2014) (138KB PDF) - Updated 12/2009
pdf 2015 Medicare Part D Drug Reimbursement form (Medicare members only, for drugs you paid for in 2015 (253KB PDF) - Added 01/09/2015
pdf 2015 Medicare Medical Service Reimbursement form (51KB PDF)
pdf PriorityVision/EyeMed out-of-network vision services claim form (76KB PDF) - Updated 01/2014
Get reimbursed for out-of-network vision services.
pdf *Dental Claim form (514KB PDF) - Updated 05/2009
Request credit against your deductible
pdf
*Health Savings Account (HSA) Member Deductible Credit Request form (91KB PDF) - Updated 11/2011
Allows members who met part of their current year deductible with a previous health plan to be credited for that amount by Priority Health.
pdf *Deductible Credit Request form (495KB PDF) - Updated 02/2010
Flexible spending account (FSA) withdrawal requests
pdf
*Flexible Spending Account (FSA) Withdrawal Request form (194KB PDF) - Updated 11/2010
To request withdrawals from your FSA account (medical, dependent care).
NOTE: If you have an HSA too, use the Limited Flexible Spending Account Withdrawal Request form, below.
pdf *Limited Flexible Spending Account (FSA) Withdrawal Request form (235KB PDF) - Updated 02/2010
For use to request withdrawals from your Flexible Spending Account (FSA) when you also have a Health Savings Account (HSA).
Give or remove HIPAA authorization
pdf *HIPAA Authorization form (174KB PDF) - Updated 06/2013
pdf *HIPAA Authorization form, Spanish (172KB PDF) - Updated 06/2013
pdf *Revocation of HIPAA Authorization form (166KB PDF) - Updated 06/2013
pdf *Revocation of HIPAA Authorization form, Spanish (124KB PDF) - Updated 06/2013
Print a HealthbyChoice (HbC) qualification form

!

Check your ID card to be sure you're choosing your HbC plan!
pdf HbC Incentives (96KB PDF) - Updated 03/2015
pdf HbC Motivations (153KB PDF) - Updated 03/2015
pdf HbC Progressions (153KB PDF) - Updated 03/2015
pdf HbC Achievements (175KB PDF) Oakland University only - Updated 02/2015
File a grievance
Learn about the steps to follow to file a complaint, or "grievance," with Priority Health.
Web page
Web page
Grievance form
To file a grievance, fill out and submit this secure online form.
Get medical services
Forms for requesting medical services
pdf Diabetes Retinopathy Evaluation form (61KB PDF) - Updated 04/2009
   Healthy Michigan Plan Health Risk Assessment Form (697KB DOCX) - Added 4/1/2014
Last modified: 3/4/2015
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