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 
Sign up to have your Medicare plan premiums automatically deducted from your bank account.
*Appointment of Representative form available on the CMS website
Name someone who can act for you for Medicare plan enrollment, claims and grievances.
pdf *Medicare Appeal Form
Appeal a coverage decision using this form. Learn about the Medicare appeals process.
pdf *Express Scripts Home Delivery Order Form
Use this form to order prescriptions by mail.
pdf Reimbursement request forms for Medicare members:
*Medical expense reimbursement request form
*Prescription expense reimbursement request form
*Ask 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
pdf Request a drug that is not on the formulary
This form is on the website of the Centers for Medicare and Medicaid Services (CMS).
pdf Medicare Advantage Disenrollment form 
Use this form if you are eligible to disenroll from our Medicare Advantage plan.
Change your name, address, dependents, PCP or plan
pdf *Change PCP form 
To change your primary care physician, it's faster to log in to your account and click "Change my doctor." Or, use these other options.
pdf *Change of status or plan form
To make changes to your name, marital status and contact information, or add or remove dependents. File within 31 days of the change.
pdf *MyPrioritySM change of status or plan form
To make changes to your name, marital status and contact information, or add or remove dependents; or, change from one MyPriority plan to another. File within 31 days of the change.
pdf MyPriority special enrollment period enrollment form 
Enroll in a MyPriority individual plan when you have had a qualifying life event.
pdf MyPriority special enrollment period child-only enrollment form
Enroll a child in a MyPriority individual plan.
Enroll in or change your FSA
pdf *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 /change from automatic bill payment
pdf *Medicare plan members Automatic Bill Payment Enrollment form 
Sign up to have your Medicare plan premiums automatically deducted from your bank account.
pdf 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
pdf *Express Scripts Home Delivery Order Form
Have your prescriptions delivered through mail order.
Submit a claim for us to reimburse you
pdf *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
pdf Medicare Part D Drug Reimbursement form 
pdf Medicare Medical Service Reimbursement form 
pdf PriorityVision/EyeMed out-of-network vision services claim form 
Get reimbursed for out-of-network vision services.
pdf *Dental Claim form
Request credit against your deductible
pdf
*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.
pdf *Deductible Credit Request form
Flexible spending account (FSA) withdrawal requests
pdf
*Flexible Spending Account (FSA) Withdrawal Request form
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 
For use to request withdrawals from your Flexible Spending Account (FSA) when you also have a Health Savings Account (HSA).
Give or remove permission to see your account/personal information
(HIPAA authorization)
pdf *HIPAA Authorization form
pdf *HIPAA Authorization form, Spanish
pdf *Revocation of HIPAA Authorization form
pdf *Revocation of HIPAA Authorization form, Spanish
Print a HealthbyChoice (HbC) qualification form

!

Careful! Choose by plan name (check your membership card) then by the date your plan year started.
pdf HealthbyChoice Incentives forms:
When did your plan year start? Before July 2016 OR July 2016 and after
pdf HealthbyChoice Motivations forms:
When did your plan year start? Before July 2016 OR July 2016 and after
pdf HealthbyChoice Progressions forms:
When did your plan year start? Before July 2016 OR July 2016 or after
pdf HealthbyChoice Achievements forms, Oakland University only:
2016 plan start date  OR 2017 plan start date
File a complaint
Learn about the steps to follow and get the forms to file a complaint, or "grievance," with Priority Health.
Web page
Get medical services
Forms for requesting medical services
pdf Diabetes Retinopathy Evaluation form
Healthy Michigan Plan Health Risk Assessment Form
Last modified: 7/22/2016
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