Provider forms

Find general Priority Health forms below.

Authorization forms: Go to the Drug authorization & billing page or the Authorizations page.

Prior notification form: Genetics medical policy prior notification form regarding counseling, testing and screening.

Appeals forms

Behavioral health forms

Change notification forms

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 

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HealthbyChoice® qualification forms

Or choose a form by plan name:

Healthy Michigan Plan assessment forms

HIPAA forms

Miscellaneous administrative forms

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 - 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.

Well child exam forms