Member forms

• Medicare Declaration of Prior Prescription Drug Coverage form (LEP form)
• Medicare address change form - Interactive form
• Appointment of Representative form - Interactive form
  Name someone who can act for you for Medicare plan enrollment, claims and grievances.
• Medicare appeal form - Interactive form
  Appeal a coverage decision using this form.
  Learn about the Medicare appeals process.
• Medicare Advantage disenrollment form - Interactive form
  Use this form if you are eligible to disenroll from our Medicare Advantage plan.
• Enhanced Dental and Vision package disenrollment form - Interactive form
  Use this form if you are eligible to disenroll from our optional Enhanced Dental and Vision package.
• Request a coverage determination for a Part D drug

Enroll in automatic bill payment

Sign up to have your Medicare plan premiums automatically deducted from your bank account or credit card by logging into your member account and clicking Billing and Set up/manage automatic payments.

Login to enroll online

Prefer to print or email your form? Use the form below.

• Enroll in automatic bill payment - Interactive form

Medicare reimbursement request forms

• Medical expense reimbursement request form - Interactive form
• Prescription expense reimbursement request form
• Prescription expense reimbursement request form, Spanish
• Request for reimbursement for out-of-country expenses - Interactive form
• Delta Dental services claim form - Interactive form
• Out of network vision services claim form - Interactive form, Priority Health Vision

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 form
• Change of status or plan form - Interactive form
  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.
• MyPriority information change form - Interactive form
  Use this form to make changes to your name, marital status and contact information, or add or remove dependents. File within 60 days of the change.

• HIPAA authorization form - Digital form
• HIPAA authorization form - Interactive form
• HIPAA authorization form, Spanish - Interactive form
• Revocation of HIPAA authorization form - Digital form
• Revocation of HIPAA authorization form - Interactive form
• Revocation of HIPAA authorization form, Spanish - Interactive form

• Member reimbursement form 
  Ask us to pay you back for health care or medications you purchased that your plan should cover.
• Member reimbursement form, out-of-country expenses - Interactive form
• PriorityVision/EyeMed out-of-network vision services claim form

• Delta Dental claim form - Interactive form

Medicaid

• Medicaid mileage reimbursement form
• Medicaid mileage reimbursement form, Spanish

• Medicaid member instructions for digital mileage reimbursement form

Enroll in automatic bill payment

Sign up to have your plan premiums automatically deducted from your bank account or credit card by logging into your member account and clicking Billing and Set up/manage automatic payments.

Login to enroll online

Prefer to print or email your form? Use the forms below.  

• Medicare plan members automatic bill payment enrollment form - Interactive form
  Sign up to have your Medicare plan premiums automatically deducted from your bank account
• MyPriority plan members premium payment method change form - Interactive form
  Sign up to have your MyPriority plan premiums automatically deducted from your bank account, or to change from automatic deductions to paying your bills by mail.

• *Health Savings Account (HSA) member deductible credit request form
  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
  Allows members with a non-calendar-year deductible plan to request credit towards their deductible.
• *Calendar year deductible credit request form
  Allows members on a calendar-year-deductible plan (deductible renews on Jan. 1) to request credit towards their deductible.

• Flexible Spending Account (FSA) enrollment/change form - Interactive form
  To enroll when your employer provides PriorityFSA^SM flexible spending account benefits, or to change your payroll deductions.

Learn about the steps to follow and get the forms to file a complaint, grievance, or appeal with Priority Health.

Healthy Michigan Plan Health Risk Assessment form (English, Spanish, and Arabic) from the Michigan Department of Health & Human Services

• Health Risk Assessment form (PDF)
• Spanish version (PDF)
• Arabic version (PDF)

This form permits a member to direct their Primary Care Physician (PCP) to avoid prescribing opioids to treat pain.

• Nonopioid directive form

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 card, or vehicle registration.