Provider forms

Appointment of Representative (Medicare) - 03/2013

Appointment reminder card, black & white - 08/2014

Appointment reminder card, color - 08/2014

Appeals forms

Behavioral health forms

Change notification forms

Claim Refund Check form - 01/2014

CPT Code Add Request form - 04/2014

Credentialing forms

Direct deposit and electronic funds transfer (EFT) form

DME/P&O Prior Authorization form - 04/2014

HealthbyChoice® qualification forms

Or

Choose a form first by plan name, then by the plan effective date:

Healthy Michigan Plan forms

Hearing Services Claim Form, Priority Health Hearing Out-of-Network (Medicare) - 01/2016

HIPAA forms

Home Safety Assessment form, Medicare - 12/2015

Home Safety Assessment Summary form, Medicare - 12/2015

Medical Prior Authorization form - 10/2015

  • Request prior authorization for medical services both in and out of network, complete online and save it for your records, then print and fax it to Priority Health.
  • Request a pre-service organization determination when a Priority Health Medicare Advantage member is seeking services that may not be covered.

Medical Services Questionnaire - 04/2014

Medication Reconciliation form, Medicare - 12/2015

Medicare Waiver of Liability (non-participating provider) - 03/2017
Complete online and save it for your records, then print and fax it to Priority Health.

Member Injury Questionnaire - 04/2014

Modifier 22 Explanation form - 04/2014

Non-coverage notification forms

  • Patient Acknowledgment of Financial Responsibility - non-Medicare only - 06/2014
  • Notice of Medicare non-coverage - Medicare Advantage patients only, for use by Skilled Nursing Facilities (SNF) only - 08/2014
    The NOMNC must remain two (2) pages and cannot be condensed into one page nor can information be moved from page 1 or page 2 to accommodate large logos or address headers. Logos and addresses can only appear at the top of the form. CMS provides this information in the NOMNC form instructions found on FFS ED Notices.

PCP patient discharge/transfer of records form - 03/2016

PCP patient reassignment within a practice spreadsheet - 12/2014

Prenatal Class billing form - 05/2014

W-9: Go to the IRS website for this form

Well child exam forms