Provider forms

Find general Priority Health forms here. For authorization forms, see the Drug authorization pages or the medical, surgical and device authorization forms page.

Appointment of Representative (Medicare) - 03/2013

Appointment reminder card, black & white - 08/2014

Appointment reminder card, color - 08/2014

Appeals forms

Behavioral health forms

Change notification forms

Claim Refund Check form - 01/2014

CPT Code Add Request form - 04/2014

Credentialing forms

Direct deposit and electronic funds transfer (EFT) form

DME/P&O Prior Authorization form - 04/2014

HealthbyChoice® qualification forms

Or choose a form by plan name:

Healthy Michigan Plan forms

Hearing services forms

  • Hearing Services Claim Form, Priority Health Hearing Out-of-Network (Medicare) - 01/2016
  • HIPAA forms

    Home Safety Assessment form, Medicare - 12/2015

    Home Safety Assessment Summary form, Medicare - 12/2015

    Medication Reconciliation form, Medicare - 12/2015

    Medicare Waiver of Liability (non-participating provider) - 03/2017
    Complete online and save it for your records, then print and fax it to Priority Health.

    Member Injury Questionnaire - 04/2014

    Modifier 22 Explanation form - 04/2014

    Non-coverage notification forms

    • Patient Acknowledgment of Financial Responsibility - non-Medicare only - 06/2014
    • Notice of Medicare non-coverage - Medicare Advantage patients only, for use by Skilled Nursing Facilities (SNF) only - 08/2014
      The NOMNC must remain two (2) pages and cannot be condensed into one page nor can information be moved from page 1 or page 2 to accommodate large logos or address headers. Logos and addresses can only appear at the top of the form. CMS provides this information in the NOMNC form instructions found on FFS ED Notices. 

    PCP patient reassignment within a practice spreadsheet - 12/2014

    W-9: Go to the IRS website for this form

    Well child exam forms