Important Forms for Our Members
Priority Partners provides immediate access to required forms and documents to assist our
providers in expediting claims processing, prior authorizations, referrals, credentialing and more.
Here are some forms you may need to help you manage your health coverage.
Authorization for Release of Health Information – Standing
This form lets you choose someone you trust to have access to your health records. You can also decide how much of your personal health information you want that person to know. Do not worry, if you do not fill out this form, Priority Partners will continue to keep your health information protected and private.
Authorization for Release of Health Information – Specific Request
Like the “standing” version of this form, you can choose someone you trust to have “one-time” access to a specific part of your personal health information. Do not worry, if you do not fill out this form, Priority Partners will continue to keep your health information protected and private.
Pharmacy Compound Drug Prior Authorization Form
If your doctor is not able to substitute an ingredient in a medication or prescribe a different drug to you, they will need to fill out this form to request prior authorization for a compound drug.
Pharmacy Prescription Reimbursement Standard Claim Form
If you previously paid for prescriptions without using your Priority Partners insurance, you can fill out this form to start the reimbursement process. Note: Your request will be reviewed, and reimbursement is not guaranteed.
Pharmacy Prescription Reimbursement Secondary Claim Form
This form should be used ONLY if you are submitting claims for secondary prescription coverage. Note: Your request will be reviewed, and reimbursement is not guaranteed.
Pharmacy Prior Authorization Form
Drugs that are not listed in the formulary must be approved by your doctor before they can be filled at the pharmacy. In order for your doctor to request that Priority Partners cover a medication for you, print this form and take to your PCP to fill out and submit.
Representation of Responsibility for Minor Child
If you are over 18 years old, filling out this form will give you the right to represent and make health care information-related decisions about a minor child who is 17 years old or younger. The adult representative can only be the minor’s parent, stepparent, legal guardian or kinship caregiver.
Paper Versions of All Member Forms Can Be Mailed to You.
All documents are available in paper form without charge. To request a paper copy, please call Customer Service at:
Monday through Friday, 8 a.m. to 5 p.m.