Forms for members of Medicare plans

You'll find these forms plus claim forms and more in the Member Handbook section of priorityhealth.com.

• Enroll in the Enhanced Dental plan (members of Medicare Advantage plans only):
  Enrollment form (227KB PDF)
  Form number Y0056_2000_2001_29 CMS-approved 09202011
• Appoint someone to act for you:
  Appointment of Representative form (98KB PDF)
  Form number H2320_3000_3005_3; H4875_3000_3005_3 F&U; S5857_3000_3005_3; all F&U (12/2009)
• Set up automatic premium payments: 
  Online Automatic Bill Payment Enrollment Form to submit directly to us (coming soon)
  OR
  Automatic Bill Payment Enrollment Form (72KB PDF) to print and mail
  Form number NCMS_2000_2004_G 02112011 
• Ask for a transition fill if you are taking a drug not on the formulary and you need a refill before you can see your doctor to discuss your options.
  Go to information for plan members about transition fills.
• Ask for an exception to the formulary if a drug you need is not covered by your plan.
  Your doctor will need to complete and sign this form for you:
  Medicare Part D Coverage Determination Request (237KB PDF)
  Form number H2320_3000_3001_158; H4875_3000_3001_158; S5857_3000_3001_158, all F&U (12/2009)
  OR
  Use the government's "Request a Medicare Prescription Drug Determination" form:
  Online form at the CMS website
• File an appeal after we send you written notice that we made a coverage decision not in your favor:
  Online Priority Health Medicare appeal form
  Priority Health Medicare appeal form (15KB PDF)

Claim/reimbursement form

• Ask to be reimbursed when you have paid for medical services or drugs
  Medicare Member Reimbursement form (132KB PDF)

Disenrollment forms

Use these forms if you are eligible to disenroll from our Medicare Advantage or Prescription Drug plan.

• Medicare Advantage Disenrollment form (489KB PDF)
  Form number Y0056_2000_2010_16 CMS-approved 12082011
• PriorityMedicare Rx^SM Disenrollment form (438KB PDF)
  Form number S5857_2000_2010_14 CMS-approved 12012011

Forms for doctors and other health care providers

Coverage Determination Request form

• Your doctor can use this form (254KB PDF) to request that Priority Health authorize some drugs and services for you.

Drug prior authorization forms

• Your doctor will use these forms to request prior authorization for any of the drugs listed on your plan's formulary that require prior authorization.
• These forms are listed in the provider section of the priorityhealth.com website.

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