Member forms

Forms marked * are interactive, so you can type information right into them. You may also be able to save the completed forms to your computer. See instructions on the left.

Jump down to these form categories:

Medicare plan member forms

*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 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.

*Express Scripts Home Delivery Order form
Use this form to order prescriptions by mail.

Reimbursement request forms for Medicare members:
*Medical expense reimbursement request form
*Member reimbursement form, out-of-country expenses
*Prescription expense reimbursement request form
*Ask for reimbursement for out-of-country expenses
Delta Dental services claim form
Hearing services claim form
Out of Network Vision Services Claim form, Priority Health Vision

Request a drug that is not on the formulary
This form is on the website of the Centers for Medicare and Medicaid Services (CMS).

Medicare Advantage Disenrollment form 
Use this form if you are eligible to disenroll from our Medicare Advantage plan.

Vision, Dental and Hearing package Disenrollment form 
Use this form if you are eligible to disenroll from our optional Vision, Dental and Hearing plan.

Change your name, address, dependents, PCP or plan

*Change PCP form 
To change your primary care physician, it's faster to log in to your account and click Change my doctor." Or, use these other options.

*Change of status or plan 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 change of status or plan form
To make changes to your name, marital status and contact information, or add or remove dependents. File within 31 days of the change.

Enroll in or change your FSA

*Flexible Spending Account (FSA) Enrollment/Change form 
To enroll when your employer provides PriorityFSASM flexible spending account benefits, or to change your payroll deductions.

Enroll in/change from automatic bill payment

*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.

Order prescriptions delivered to your home

*Express Scripts Home Delivery Order Form
Have your prescriptions delivered through mail order.

Submit a claim for us to reimburse you

Request credit against your deductible

*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.

Give or remove permission to see your account/personal information (HIPAA authorization)

Print a HealthbyChoice (HbC) qualifications form

Careful! Choose by plan name (check your membership card).

HealthbyChoice Incentives forms

HealthbyChoice Motivations forms

HealthbyChoice Progressions forms

HealthbyChoice Achievements forms, Oakland University only

File a complaint

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

  • Go to the regular grievance process 
  • Go to the Medicare grievance process 
  • Go to the FEHB grievance process 
  • Get medical services

    Forms for requesting medical services 

    Healthy Michigan Plan Health Risk Assessment Form (English, Spanish, and Arabic)