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Enrollment & Dependent Forms

Enrollment/Change Form - New Hampshire

Enrollment/Change Form - New York

Enrollment/Change Form - Vermont

Enrollment/Change Form - Vermont Individual
Indemnity Plan (ViiP)

Enrollment/Change Form for Chamber and
Multi-Employer Groups

Healthy NY Annual Re-Certification for Individuals and
Sole Proprietors

Disability Eligibility Determination Form PCP

Disability Eligibility Determination Form Subscriber

Student/Dependent Coverage Claim Form

College Student Waiver Form for Out of Area Coverage (Medical)

College Student Waiver Form (Dental)

Medical Questionnaire

Behavioral Health- ValueOptions® Forms

Authorization to Disclose Health Information

Mental Health/Substance Abuse Treatment Claim


Authorization to Disclose

Authorization to Disclose (Spanish)

Prior Authorization Guide for Members

Health Information Exchange

How $1 of Health Care Premium is Spent

PPO and Indemnity Plans: Out-of-Network Claims

Unclaimed Property Claim Form



Claims & Reimbursement Forms

Medical Reimbursement

Dental Claim Form (American Dental Association)

Child Preparation Reimbursement

HealthDollars Federal Reimbursement

HealthDollars State Reimbursement

Trivantage HMO HealthDollars Reimbursement

New Hampshire HealthFirst Wellness Verification Form

Wellness Programs Reimbursement Form

WellStyle Rewards Program 2013 - Health Risk Screening Form

NY Exchange (On/Off) $600 Gym Reimbursement Form for Standard Plans

Manage Prescriptions

Prescription Drug Forms


Living Well Newsletter

Advance Care Planning - New York

NYSBA Living Will and Health Care Proxy Forms


New York State Department of Health

Organ and Tissue Donations

Medical Orders for Life Sustaining Treatment (MOLST)


HMO Member Handbook

MVP Option

MVP Option Family

MVP Option (Spanish)

MVP Option Family (Spanish)

Forms can vary by plan/region. The first character/number of the member/subscriber ID tells us the form(s) you need.

Note: For CIGNA patients please visit

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