Member forms
Forms marked "Interactive" allows you to type information right into them.
Follow the instructions on the form to find out where to send it once you've completed filling it out.
If you have questions, contact our customer service team by calling the number on the back of your membership card.
- Enroll in automatic bill payment - Interactive
Sign up to have your Medicare plan premiums automatically deducted from your bank account. - Appointment of Representative form - Interactive, available on the Centers for Medicare & Medicaid Services (CMS) website
Name someone who can act for you for Medicare plan enrollment, claims and grievances. - Medicare appeal form - Interactive
Appeal a coverage decision using this form.
Learn about the Medicare appeals process. - Medicare Advantage disenrollment form - Interactive
Use this form if you are eligible to disenroll from our Medicare Advantage plan. - Enhanced Dental and Vision package disenrollment form - Interactive
Use this form if you are eligible to disenroll from our optional Enhanced Dental and Vision package.
Communication impediment designation form
This form is for drivers and/or occupants in a vehicle who are deaf, hearing-impaired, or autistic. You can request a special "communication impediment" designation be placed on your Secretary of State record to notify law enforcement about your and/or your occupants specific communication needs. The designation is voluntary and is not printed on your driver's license, state ID care, or vehicle registration.
Medicare reimbursement request forms
- Medical expense reimbursement request form - Interactive
- Prescription expense reimbursement request form
- Prescription expense reimbursement request form, Spanish
- Request for reimbursement for out-of-country expenses - Interactive
- Delta Dental services claim form
- Out of network vision services claim form - Interactive, Priority Health Vision
Change your primary care physician, address and more
It's fastest to change your PCP online. Log in to your member account and choose My health care, then Find a Doctor.
- Change PCP form - Interactive
- Medicare address change form
- Change of status or plan form - Interactive
Use this form to make changes to your name, marital status and contact information, or add or remove dependents. File within 31 days of the change.
Prescription drugs
- Medicare Declaration of Prior Prescription Drug Coverage form (LEP form)
- Request a drug that is not on the formulary on the CMS website
- Nonopioid directive form
This form permits a member to direct their Primary Care Physician (PCP) to avoid prescribing opioids to treat pain.
Request credit against your deductible
- Health Savings Account (HSA) member deductible credit request form - Interactive
Allows members who met part of their current year deductible with a previous health plan to be credited for that amount by Priority Health. - Deductible credit request form - Interactive
Allows members with a non-calendar-year deductible plan to request credit towards their deductible. - Calendar year deductible credit request form - Interactive
Allows members on a calendar-year-deductible plan (deductible renews on Jan. 1) to request credit towards their deductible.
Give or remove permission to see your personal information (HIPPA authorization)
- HIPAA authorization form - Interactive
- HIPAA authorization form, Spanish - Interactive
- Revocation of HIPAA authorization form - Interactive
- Revocation of HIPAA authorization form, Spanish - Interactive
Health Risk Assessment
Healthy Michigan Plan Health Risk Assessment form (English, Spanish, and Arabic) from the Michigan Department of Health & Human Services