Member Forms

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.

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.

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.

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.

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.

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.

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.