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ABOUT SSL CERTIFICATES

Complete our online application form

Before you begin:
You will need your red, white and blue Medicare card.

You will need your bank or other financial institution's "routing number."

If you want to print out a copy of the application, click this link:
Print a copy of the Priority Health Medigap plan application form (140KB PDF)
If you prefer, you may fill out the printed version and mail it to:
Priority Health, 1231 East Beltline Avenue, MS 1175, Grand Rapids, MI, 49525.

Personal information











































Select a Priority Health Medicare Supplement Plan




You must be enrolled in Medicare Part A and B, you can’t have more than one Medicare Supplement Plan and cannot be enrolled in a Medicare Supplement and Medicare Advantage plan at the same time. Refer to the Outline of Coverage for the monthly cost of the plan and description of the plan. You must also be a permanent resident of Michigan and physically reside there seven months out of every year.

Your coverage will become effective on the first day of the month following receipt and approval of your completed application, or a date specified in your application. The date must be in the future. You will receive an I.D. card and a certificate confirming your effective date and premium. If you would like coverage to begin at a later date, please indicate below:

Your acceptance may be guaranteed Are you in your open enrollment period?




Are you in a guaranteed issue period?

If yes, please mail a copy of the termination notice to 1231 E Beltline Avenue, MS 1175, Grand Rapids, MI, 49525.


If you answer "yes" to any of the questions above, you are guaranteed acceptance into certain Priority Health Medicare Supplement Plans.
Questions about Medicaid
  1. Will Medicaid pay your premiums for this Medicare Supplement policy?
    Yes    No

  2. Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium?
    Yes    No
Questions about Medicare Replacement Coverage If you had coverage from any Medicare plan other than Original Medicare within the past 63 days (for example, a Medicare Advantage plan, or a Medicare HMO or PPO), fill in your start and end dates below. If you are still covered under this plan, leave "End" blank.
Start: End:

If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare Supplement policy?
Yes    No

Was this your first time in this type of Medicare plan?
Yes    No

Did you drop a Medicare Supplement policy to enroll in this Medicare Supplement plan?
Yes    No
Questions about Medicare Supplement, Medicare Select Do you have another Medicare Supplement policy in force?
Yes    No

If yes, with what company, and what plan do you have?

Company:


Plan:


If yes, do you intend to replace your current Medicare Supplement policy with this plan?
Yes    No
Questions about any other health insurance Have you had coverage under any other health insurance within the past 63 days? (For example, an employer, union, or individual plan)?
Yes    No

If so, with what company and what kind of policy?
Company:


Kind of policy:


What are your dates of coverage under the other policy? If you are still covered under this plan, leave "End" blank.
Start: End:
Additional information
  • You do not need more than one Medicare Supplement plan.
  • If you purchase this plan, you may want to evaluate your existing health coverage and decide if you need multiple coverages.
  • If you are 65 or older, you may be eligible for benefits under Medicaid and may not need a Medicare Supplement plan.
  • Your coverage will automatically be renewed each year as long as you pay your premiums.
  • If, after purchasing this plan, you become eligible for Medicaid, the benefits and premiums under your Medicare Supplement plan will be suspended during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days of becoming eligible for Medicaid. If you are no longer entitled to Medicaid, your suspended Medicare Supplement plan may be available. If it is no longer available, a substantially equivalent plan will be reinstated if requested within 90 days of losing Medicaid eligibility.
  • To terminate your plan please notify Priority Health in writing 30 days prior to termination.
  • Counseling services may be available in your state to provide advice concerning your purchase of Medicare Supplement insurance
    and concerning Medicaid.
Health information If you are applying for coverage during your open enrollment or guaranteed issue period, please skip down to the "Payment information" section.

  1. Cancer (except non-melanoma skin cancer) or leukemia?
    Yes    No

  2. Alzheimer's disease, amyotrophic lateral sclerosis, multiple sclerosis, muscular dystrophy, Parkinson's disease or senile dementia?
    Yes    No

  3. Acquired immune deficiency syndrome (AIDS) or AIDS-related complex (ARC)?
    Yes    No

  4. Angina pectoris, stroke, congestive heart failure (CHF), coronary artery disease (CAD), or vascular disease?
    Yes    No

  5. Chronic kidney disease or disorder including end-stage renal disease (ESRD) or dialysis?
    Yes    No

  6. Emphysema, chronic obstructive pulmonary disease (COPD), chronic bronchitis, or tuberculosis?
    Yes    No

  7. Cirrhosis of the liver or hepatitis B or C?
    Yes    No

  8. Diabetes or hemophilia?
    Yes    No

  9. Organ transplant to include heart, liver, kidney, pancreas, lung, or bone marrow?
    Yes    No
Your response to the following questions may influence your eligibility and/or monthly premium. Once your application is processed, we will advise you of your monthly premium for the plan you choose.

Read the following questions carefully. If you answer "yes" to questions 10 - 12, please provide additional information in the section below.
  1. Are you currently disabled, hospitalized or confined to a facility such as a skilled nursing facility?
    Yes    No

  2. Has a physician advised you to have treatment, medical tests, surgery or therapy for any condition in the next 12 months (including hospitalization or confinement to a facility)?
    Yes    No

  3. Have you been hospitalized or confined to any facility more than once in the past 12 months?
    Yes    No

  4. Have you used tobacco products in the past 12 months?
    Yes    No

  5. Please provide the following:
    Height: Weight:
If you answered "yes" to any item in questions 10-12, please explain below including your diagnosis and treatment (list date of service and treatment details – include physician visits, hospitalizations, surgeries, etc., and all medications prescribed):
Payment information Choose a payment option:
Receive a bill monthly and pay the plan directly by mail
Electronic funds transfer (EFT) from your bank account each month

On the first day of every month, the checking or savings account you designate will be debited for the amount of your premium.
You will receive a billing statement each month approximately ten (10) days before your account will be debited.

If you have questions about the automatic bill payment plan, please contact Customer Service at 800 852-9780. (There will be a $50
charge for the first transfer returned. A second non-sufficient funds (NSF) return will result in termination of coverage.)











Authorization and verification information By completing and submitting this application form, I agree to the following:

I have read and understand the contents of this application. I declare that the answers on this application are complete and true to the best of my knowledge and belief and are the basis for issuing coverage. I understand that the application and amendments become a part of the insurance contract and that if the answers are incomplete, incorrect or untrue, Priority Health may have the right to rescind my coverage, adjust my premium, or reduce my benefits.

I understand that any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act when determined by a court of competent jurisdiction, and as such may be subject to criminal and civil penalties.

I understand the coverage under the plan I am applying for will not take effect until issued by Priority Health. Priority Health requires proper handling of personal health information for its members. Details of Priority Health's confidentiality policies and procedures are available upon request.

I have received a copy of the Priority Health Medicare Supplement Plans Outline of Coverage:
Yes    No

I have received a copy of Choosing a Medigap Policy:
Yes    No

I understand that the following parties may need to collect information on me in regard to the proposed coverage: Priority Health and its reinsurers; any insurance support organization; any consumer reporting agency; and all persons authorized to represent these organizations for this purpose.

The following information may be disclosed to or by Priority Health: any and all individually identifiable health information, including but not limited to medical records, reports, pharmaceutical records, diagnostic testing and lab work results.

Those parties that may need to collect information may disclose information to the following: other insurers to which I have applied or may apply; reinsurers, pharmacy benefit managers, physicians, hospitals, clinics or other medically related facilities, health care clearing houses; or persons who perform business, professional, or insurance tasks for them. They may disclose information as allowed or required by law.

I understand that this authorization is needed for the purpose of gathering information to making eligibility, underwriting and risk rating determinations. Unless revoked earlier, this authorization will be valid for thirty (30) months after the date it is signed.

I understand that I can revoke this authorization at any time by giving written notice to Priority Health at 1231 E Beltline Avenue, NE, MS 1175, Grand Rapids, MI 49525. I also understand that my revocation will not affect the rights of any individual who has acted in reliance on the authorization prior to receiving notice of my revocation.

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment.

I understand that there is a possibility of redisclosure of any information disclosed pursuant to this authorization and that information, once disclosed, may no longer be protected by federal rules governing privacy and confidentiality.


If you are the authorized personal representative, you must provide the following information:

First name:


Last name:


Address:


City:


State:


ZIP code:


Phone number (include area code):


Relationship to applicant:
Agency form: to be completed by insurance agent If you are applying directly without an agent skip this section.

Have you sold any other policies to this individual which are still in force?
Yes    No

If yes, please submit documentation with application.

Have you sold any policies to this individual in the last five (5) years that are not still in force?
Yes    No

If yes, please submit documentation with application.

Please list any other health insurance policies you have personally sold to the applicant that are still in force. If none, please write none. Also, list any policies you sold to the applicant in the past five (5) years that are no longer in force.
(e.g. PriorityHMO - not in force)


I asked the applicant all the questions in this application and the answers are recorded as given to me:
Yes    No

Agency name:


Tax ID number:


Agent first name:


Agent last name:


Agent number:


Street address:


City:


State:


ZIP code:


E-mail address:


Agent primary phone (include area code):


Agent fax (include area code):


E-signature:
Do you declare that the answers on this application are complete and true to the best of your knowledge?
Yes
No
Notice to the applicant Regarding replacement of Medicare supplement coverage.

According to your application or the information you have furnished, you intend to drop or otherwise terminate existing Medicare Supplement coverage or Medicare Advantage plan and replace it with a certificate to be issued by Priority Health. Your new certificate provides thirty (30) days within which you may decide, without cost, whether you desire to keep the certificate.

You should review this new coverage carefully, comparing it with all disability and other health coverage you now have. You should terminate your present coverage only if, after due consideration, you find that purchase of this Medicare Supplement coverage is a wise decision.

Statement to applicant by Priority Health, agent, broker or other representative: I have reviewed your current medical or health coverage as disclosed to me. The replacement of coverage involved in this transaction does not duplicate your existing Medicare Supplement, or, if applicable, Medicare Advantage coverage because you intend to terminate your existing Medicare Supplement coverage or leave your Medicare Advantage plan, to the best of my knowledge. The replacement plan is being purchased for the following reasons:
Additional benefits
No change in benefits, but lower premiums
Fewer benefits and lower premiums
My plan has outpatient prescription drug coverage and I am enrolling in Part D
Disenrollment from a Medicare Advantage plan. (Please explain reason for disenrollment)

Other (please specify)


If, after thinking about it carefully, you still wish to drop your present coverage and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical and health history. Failure to include all material medical information on an application may provide a basis for the insurer to deny any future claims and to refund your premium as though your policy or certificate had never been in force. After the application has been completed, review it carefully to be certain that all information has been properly recorded.

Do not cancel your present policy until you have received your new certificate and are sure that you want to keep it.




It is required the above "Notice to Applicant" is read by the applicant and the authorized representative.

Applicant's e-signature:
I, the applicant, have read the "Notice to Applicant" section above:
Yes    No

Agent's e-signature:
I, the agent, broker, or other representative, have read the "Notice to Applicant" section above:
Yes    No

Print

WARNING: PRINT FIRST, THEN CLICK "APPLY." 
You will not be able to print it after you click "Apply." The "Notice to applicant" may be important to you in the future.

Click APPLY to get a confirmation number for your records.

Updated: July 08, 2010

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