Priority Partners Forms

Priority Partners provides immediate access to required forms and documents to assist our providers in expediting claims processing, prior authorizations, referrals, credentialing and more.

• Authorization for Release of Health Information - Specific Request
• Hepatitis C Therapy Prior Authorization Request
• Medical Admission or Procedure Authorization Request (not for medical injectable requests)
• Medical Review Medical Injectable Prior Authorization Request
• Member Referral
• Newborn Notification and Authorization Request
• Newborn Notification and Authorization Request Instructions
• Personalized Treatment Plan
• Pharmacy Prior Authorization Request (non-opioid medications only)
• Pharmacy Opioid Prior Authorization Request
• Pharmacy Compound Drug Prior Authorization Form
• Primary Care Provider Change
• Provider Appeal Submission Form
• Provider Claims/Payment Dispute and Correspondence Submission Form
• Synagis Prior Authorization Request

PLEASE NOTE: All forms are required to be faxed to Priority Partners for processing. See the fax number at the top of each form for  proper submission. If you have any questions, please contact Customer Service at 1-800-654-9728.

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