Forms

Accessing Services for Autism Spectrum Disorder (ASD)
Member instructions - July, 2013

Affidavit of Domestic Partnership
Legally establish a domestic partnership for the purposes of enrolling your partner on your health insurance plan.

Coverage Determination Form
A beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this form to request a coverage determination (prior authorization, exception, etc.) from your Medicare Advantage plan.

Disability Certification Form
Certification of an unmarried child's disability and eligibility for continued coverage.

Drug Claim Form – Member

Coordination of benefits / Direct claim form.

Drug Mail Order Form – Member
Pharmacy order form.

Drug Claim Form - Medicare Members
Form for submitting claims for Medicare Members.

Drug Mail Order Form - Medicare Members
Signing up for the mail order option provides convenient home delivery of your prescription drugs and may also save you money.

Gym Reimbursement Form

Only applicable to Platinum, Gold, Silver Standard and Bronze individual products.

Gym Reimbursement Form - Featured
Only applicable to Featured individual plans.

Gym Reimbursement Form - Small Group
Only applicable to small group products, if your employer has 2 - 50 employees.

Health Care Proxy Form
Complete this New York State document to legally appoint someone you trust, such as a family member or close friend, as your healthcare agent; to make healthcare decisions for you if you lose the ability to make decisions for yourself.

Medicare Certification Form
This form is used to determine Medicare eligibility.

Student Dependent Verification Form
This form must be completed to verify that your dependent age 19 or over is a full-time student at an accredited College or University.

Subscriber Claim Form
Medical benefits subscriber claim form.

Vaccine Claim Form – Medicare Members
Complete and submit for reimbursement of covered Part D vaccines and their administration.

Vision Claim Form
EyeMed out-of-network claim form.

Redetermination Form
A beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this form to request a redetermination (appeal) from your Medicare Advantage plan.


*Gym Reimbursement Forms - please reference your schedule of benefits to determine which form to download. Reimbursement levels vary depending on your product.

HIPAA Form 2(A) - Use/Disclose Protected Health Information
Completing this form permits release, in most instances, of general health information to the person(s) named in the form(s). This version does NOT allow for the release of HIV/AIDS, Mental Health, Alcohol or Substance Abuse information.

HIPAA FORM 2(D)
Authorization for Release of HIV Information
Completion of this form will ONLY allow the release of HIV/AIDS information.

HIPAA FORM 2(E)
Authorization for Release of Confidential Medical Records Related to Alcohol and Substance Abuse and Mental Health
Completion of this form will ONLY allow the release of Mental Health, Alcohol or Substance Abuse information.

Subscriber Claim Form
Medical benefits subscriber claim form.

Vaccine Claim Form 
Complete and submit for reimbursement of covered Part D vaccines and their administration.

Health Care Proxy Form
Complete this New York State document to legally appoint someone you trust, such as a family member or close friend, as your healthcare agent; to make healthcare decisions for you if you lose the ability to make decisions for yourself.

Drug Claim Form - Medicare Members
Form for submitting claims for Medicare Members.

Drug Mail Order Form - Medicare Members
Signing up for the mail order option provides convenient home delivery of your prescription drugs and may also save you money.

Coverage Determination Form 
A beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this form to request a coverage determination (prior authorization, exception, etc.) from your Medicare Advantage plan.

Redetermination Form 
A beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this form to request a redetermination (appeal) from your Medicare Advantage plan.