Provider forms

• Provider Level I appeal form - 11/2021
• Provider Level II appeal form - 04/2017

• ABA therapy authorization request form - 03/2022
• Behavioral Health Authorization request form - 03/2022
• Behavioral Health Care Coordination form - 03/2022
• Transcranial Magnetic Stimulation (TMS) authorization form - 03/2022

Submit provider changes through prism.

Change Individual Provider or Organization

Individual provider enrollments and provider organization enrollments need to be submitted through prism.

New Individual Provider Enrollment

New Organizational Provider Enrollment 

Watch video tutorial

• Online qualification tool - for all HealthbyChoice plans, all plan effective dates

Or choose a form by plan name:

• HbC Incentives form

• English: Healthy Michigan Plan health risk assessment (updated March 2018)
• Español: Examen de Riesgo de Salud y instrucciones (updated May 2018)
• Arabic:  (updated May 2018)
• Healthy Michigan Plan HRA fax cover sheet - 07/2016

• HIPAA authorization, English
• HIPAA authorization, Spanish
• HIPAA revocation of authorization, English
• HIPAA revocation of authorization, Spanish

• Appointment of representative, Medicare
• Appointment reminder card, black & white
• Appointment reminder card, color
• Claim refund check form
• Direct deposit and electronic funds transfer (EFT) form
• Hearing services claim form, Priority Health hearing out-of-network, Medicare
• Home safety assessment form, Medicare
• Home safety assessment summary form, Medicare
• Medication reconciliation form, Medicare
• Medicare waiver of liability (non-participating provider)
  Complete online and save it for your records, then print and fax it to Priority Health.
• Member injury questionnaire
• Modifier 22 explanation form
• PCP patient reassignment within a practice spreadsheet
• W-9: Go to the IRS website for this form

• 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) and Home Health Care agencies - 08/2019
  The NOMNC must remain two 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.

• Newborn to 1 week exam form
• 4 week exam form
• 2 month exam form
• 4 month exam form
• 6 month exam form
• 9 month exam form
• 12 month exam form
• 18 month exam form  
• 2 year exam form
• 30 month exam form
• 3 year exam form
• 4 year exam form
• 5 year exam form
• 6 to 10 year exam form
• 11 to 14 year exam form
• 15 to 18 year exam form