Get Member Change Form - Priority Health

This guide provides a clear and detailed overview of how to complete the Member Change Form for Priority Health online. Understanding each section of the form will help ensure that your changes are processed accurately and efficiently.

Follow the steps to fill out the Member Change Form online.

1. Press the ‘Get Form’ button to access the Member Change Form and open the document in your preferred editor.
2. Fill out the member information section by providing the member's last name, first name, middle initial, social security number, email, and phone number.
3. In the name change section, indicate whether the change is for the member or a dependent. If a name change is needed, enter the new last name and first name.
4. For address or phone changes, specify whether the change is for the member or dependent and fill in the member ID number, street address, city, state, ZIP code, and phone number.
5. If there are dependent changes, fill out the dependent information section for each dependent. Include their last name, first name, middle initial, social security number, birth date, relation to the member, address, and check their sex.
6. Specify the primary care provider, providing their name and address. Indicate whether each dependent has previously seen this provider.
7. In the authorization section, read and understand the statement regarding changes made by Priority Health. Sign and date the form to authorize the requested changes.
8. If applicable, select the plan change option and complete the employer or representative signature section.
9. Detail any reasons for dependent termination or other reasons for changes, providing necessary information as requested.
10. Once all fields are complete, you can save the changes, download, print, or share the completed Member Change Form as needed.

Complete your Member Change Form online now to ensure your changes are processed smoothly.