Print Forms
Claim Forms
To submit a claim electronically, go to Submit Claims.
To submit a claim electronically, login and go to Submit Claims page.
- Medical or Vision Claim Form
- Prescription Drug Claim Form - Use for prescriptions that were purchased and/or reimbursement for covered at-home COVID-19 tests. Refer to instructions on how to complete and submit for reimbursement of covered at-home COVID-19 tests.
- Surprise Medical Bill Certification Form - Use this form if you receive a surprise bill for health care services.
- Dental Claim Form
- Dental Rewards Claim FormOpen a PDF
- Medical Claim FormOpen a PDF
- Prescription Drug Claim FormOpen a PDF - Use for prescriptions that were purchased and/or reimbursement for covered at-home COVID-19 tests. Refer to instructions on how to complete and submit for reimbursement of covered at-home COVID-19 testsOpen a PDF.
- Surprise Bill Certification FormOpen a PDF - Use this form if you receive a surprise bill for health care services.
- Dental Claim FormOpen a PDF
FSA, HRA, and HSA Reimbursement Forms
- Reimbursement Account Forms (FSA/HRA/HSA) - Forms provided by Lifetime Benefit Solutions for Flexible Spending Account, Health Reimbursement Account, and Health Savings Account
General Forms
- Advance Care Planning - for health care proxies, living wills and more
- Manage Your Privacy
- Manage Your Privacy
- Deluxe Item Upgrade FormOpen a PDF
- Dental Rewards Claim FormOpen a PDF
Membership & Enrollment Forms
- Adult Disabled Dependent FormOpen a PDF
- Continuing Coverage for Students on Medical Leave Form Open a PDF
- Dental Coverage Attestation Form Open a PDF
- Dependent Certification FormOpen a PDF
- Member Change Form for Direct Purchase PlansOpen a PDF
- Young Adult Option Certification FormOpen a PDF - If your group renewal date has passed and you or your young adult is interested in the "Young Adult Option" use this form.
- Prior Coverage Verification FormOpen a PDF
- Healthy New York Recertification Open a PDF
Reimbursement Forms
Form 1095-B
Taxpayers are not required to include a Form 1095-B when filing their taxes.
Health insurers are no longer required to mail Form 1095-B to their members.
Click Learn More for your options.
