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 Injectable Prior Authorization Forms
• 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

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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