Member Forms

Claim forms

Medical and vision claims

• Medical or Vision Claim Form
• Medicare Advantage Medical Claim Form Medicare Only
• International Claim Form
• Formulario de reclamación internacional
• International Claim Form in European A4 Paper Size

Prescription drug claims

• Prescription Drug Claim Form
• Formulario de Coordinación de Beneficios/Reclamación de Reembolso de Medicamentos Recetados
• Medicare Advantage Prescription Drug Claim Form Medicare Only
• Dual Special Needs Plan (D-SNP) Prescription Drug Claim Form D-SNP Only

Dental claims

• Dental Claim Form

Health spending and reimbursement

• FSA, HRA, and HSA Reimbursement Forms
• Dual Special Needs Plan (D-SNP) OTC & Healthy Food Claim Form D-SNP Only
• SimplyBlue Gym Membership Incentive Reimbursement Form

Travel and lodging reimbursement

• Travel Reimbursement Form
• Medicare Advantage Transplant Travel & Lodging Claim Form Medicare Only
• Dual Special Needs Plan (D-SNP) Transplant Travel and Lodging Claim Form D-SNP Only

Coverage and billing

• Automated Premium Withdrawal Form Medicare Only
• Pediatric Dental Coverage Attestation Form
• Prior Coverage Verification Form
• Surprise Medical Bill Certification Form (PDF)
• Deluxe Item Upgrade Form

Membership and enrollment

• Adult Disabled Dependent Form
• Away From Home Care Guest Membership Application
• Continuing Coverage for Students on Medical Leave Form
• Dental Change Form — Individual & Family Plans
• Dependent Certification Form
• Medical Change Form — Individual & Family Plans
• Young Adult Option Certification Form

Privacy, authorization, and legal

• Learn about Form 1095-B
• Manage Your Privacy Forms
• Manage Your Privacy Forms
• New York Health Care Proxy Form (PDF)
• Poder de atención médica Nombramiento de su agente de atención médica en el estado de Nueva York (PDF)
• New York Designation of Representative/Authorization (PDF)

Note: Some forms may not apply to your coverage and benefits. For forms not listed here, please contact Customer Care.