Member forms
Forms labeled "Interactive" allow you to type information right into them. Follow the instructions on each form for how to fill out and submit your form.
If you have questions, contact our customer service team by calling the number on the back of your membership card.
Most used forms
Request reimbursement for a medical expense your plan should cover
Interactive form
For Medicare plans
For MyPriority, Medicaid and Group plans
Give or remove permission to see your personal information
Interactive form
For all plans
All forms
Medicare 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
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 drug that is not on the formulary on the CMS website
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.
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
Change your PCP, name, address, dependents or plan
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.
Give or remove permission to see your personal information (HIPAA authorization)
- HIPAA authorization form - Interactive form
- HIPAA authorization form, Spanish - Interactive form
- Revocation of HIPAA authorization form - Interactive form
- Revocation of HIPAA authorization form, Spanish - Interactive form
Request reimbursement for a medical expense
- 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
You can also log in to your member account to complete and submit a digital version of this form.Automatic bill payment enrollment or change
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.
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.
Request credit against your deductible
- Health Savings Account (HSA) member deductible credit request form - Interactive 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 - Interactive form
Allows members with a non-calendar-year deductible plan to request credit towards their deductible. - Calendar year deductible credit request form - Interactive 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 or change
- Flexible Spending Account (FSA) enrollment/change form - Interactive form
To enroll when your employer provides PriorityFSASM flexible spending account benefits, or to change your payroll deductions.
File a complaint or an appeal
Learn about the steps to follow and get the forms to file a complaint, grievance, or appeal with Priority Health.
Health Risk Assessment
Healthy Michigan Plan Health Risk Assessment form (English, Spanish, and Arabic) from the Michigan Department of Health & Human Services
Nonopioid directive form
This form permits a member to direct their Primary Care Physician (PCP) to avoid prescribing opioids to treat pain.
Deaf, hearing impaired, or autism resources
- Communication impediment designation form - Interactive 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.