Get Member Reimbursement Form - Priority Health

Filling out the Member Reimbursement Form for Priority Health online is a straightforward process designed to help users easily submit claims for medical expenses. This guide will walk you through each section of the form, providing clear and detailed instructions to ensure your submission is accurate and complete.

Follow the steps to complete your Member Reimbursement Form successfully.

1. Use the ‘Get Form’ button to obtain the Member Reimbursement Form and open it in your chosen editor.
2. Begin by filling out Section 1, which is the member information section. Include your contract number, member name, address, city, state, and zip code as indicated. Make sure to print clearly to avoid any processing delays.
3. If you are submitting claims for multiple family members, create a new form for each person to ensure clarity in your submissions.
4. Gather and submit an itemized statement for each medical expense. The statement should include the name of the patient, provider of service, diagnosis and description of the service, dates of service, and the amount charged for each service.
5. In Section 2, include any additional comments or a description of the claim or receipt if necessary. This section is optional but can provide helpful context for your submission.
6. Move to Section 3 and provide your signature, confirming that all statements and attachments are true and complete to the best of your knowledge. Also, include the date of your signature.
7. Finally, refer to Section 4 for submission instructions. For the quickest processing, fax the completed form and itemized statements to 616.942.0616. If you prefer to mail the form, send it to Priority Health, Attn: Claims Department, P.O. Box 232, Grand Rapids, MI 49501-0232.
8. After completing these steps, ensure you save any changes made to the form, and consider downloading, printing, or sharing the form as needed for your records.

Get started on your Member Reimbursement Form online for an efficient claims process.