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 Compound Drug Prior Authorization Form
Pharmacy Drug-Specific Prior Authorization Forms
Pharmacy Non-Specific Drug Prior Authorization Form
Pharmacy Non-Formulary Exception Prior Authorization Form
Pharmacy Quantity Limit Exception Prior Authorization Form
Pharmacy Step Therapy Exception 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.