Find general Priority Health forms below.
Authorization forms
Go to the Drug authorization & billing page or the Authorizations page.
Behavioral health forms
Go to this page for all behavioral health forms.
Provider Manual change notification forms
Provider Manual change notification forms
Submit provider changes through prism.
Provider Manual enrollments
Provider Manual enrollments
For individual providers requesting enrollment in our Medicaid plan only, we use a standardized credentialing and enrollment form submitted via email. See Medicaid-only credentialing for details.
All other individual provider enrollments and provider organization enrollments need to be submitted through prism.
Provider Manual Healthy Michigan Plan assessment forms
Provider Manual Healthy Michigan Plan assessment forms
- 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
Provider Manual HIPAA forms
Provider Manual HIPAA forms
Provider Manual miscellaneous administrative forms
Provider Manual miscellaneous administrative forms
- 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 Outpatient Observation Notice (MOON) form - English, Spanish
- 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
Provider Manual non-coverage notification forms
Provider Manual 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) and Home Health Care agencies - 04/2025
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.