Forms for Priority Health members (2024)

• Medicare Declaration of Prior Prescription Drug Coverage form(LEP form)
• Medicare address change form
• *Enroll in automatic bill payment
  Sign up to have your Medicare plan premiums automatically deducted from your bank account.
• *Appointment of Representative form 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
  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
  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

Medicare reimbursem*nt request forms

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

It's fastest to change your PCP online. Log in to your member accountand chooseMy health care, then Find a Doctor.

• *Change PCP form
• *Change of status or plan 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.
• *MyPriorityinformation change 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.

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

• *Medicare plan members automatic bill payment enrollment form
  Sign up to have your Medicare plan premiums automatically deducted from your bank account.
• *MyPriority plan members automatic bill payment change 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.

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

You can request an out-of-network claim form be mailed to you by calling the EyeMed Customer Service Department at 844.366.5127, Monday through Friday 8 a.m. to 8 p.m. EST (TTY users should call 711).

• *Delta Dental claim form

Medicaid

• Medicaid mileage reimbursem*nt form
• Medicaid mileage reimbursem*nt form, Spanish

You can also log in to your member accountto complete and submit a digital version of this form.

• Medicaid member instructions for digital mileage reimbursem*nt form

• *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.

• *HIPAA authorization form
• *HIPAA authorization form, Spanish
• *Revocation of HIPAA authorization form
• *Revocation of HIPAA authorization form, Spanish

Check your membership card and choose by plan name.

• HealthbyChoice Incentives forms

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 care, or vehicle registration.