Print Forms

Use the links below to print/view copies of our most frequently used forms.

Health-Related Forms

• Advance Care Planning - for health care proxies, living wills and more
• Manage Your Privacy

Prescription Claim Forms

For compound drugs to be considered for reimbursement by the plan, each ingredient of the compound must be found and payable in our claims system. Members who choose to pay out-of-pocket for compounded drug products will not be reimbursed if the compound contains an ingredient that is not able to be identified and payable in our claims system.

• Prescription Drug Claim FormOpen a PDF - Use for prescriptions that were purchased on, or after, Jan. 1, 2017 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.

Claim Forms

• Deluxe Item Upgrade FormOpen a PDF
• Dental Claim FormOpen a PDF
• Dental Rewards Claim FormOpen a PDF
• Medical Claim FormOpen a PDF
• valucare Gym Membership Incentive Reimbursement FormOpen a PDF
• Surprise Bill Certification FormOpen a PDF - Use this form if you receive a surprise bill for health care services.

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

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