Service and device auth request forms

General authorization form

Medical prior authorization form - Updated 12/2017

For Medicare members: Use this form to request a pre-service organization determination when a Priority Health Medicare Advantage member is seeking services that may not be covered.

Notice for Medicaid providers: In order to receive payment from any Medicaid program, new federal regulation requires that those providing services to a Medicaid beneficiary must enroll in CHAMPS (Community Health Automated Medicaid Processing System) to receive reimbursement effective March 1, 2018. For more information, go to: https://milogintp.michigan.gov or Contact the Medicaid Provider Helpline 1-800-292-2550.

Service- or device-specific forms

Behavioral health forms

Authorization forms

Other behavioral health forms

Home health care services forms

Obesity services forms

Physician-supervised weight loss program forms:

Obstructive sleep apnea device and study forms

Rehab facility forms

Transplant services forms