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

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

Claim Forms

• Dental Claim FormOpen a PDF
• Medical Claim FormOpen a PDF
• valucare Gym Membership Incentive Reimbursement FormOpen a PDF
• Surprise Bill Assignment of Benefits FormOpen a PDF - Use this form if you receive a surprise bill for health care services.

Membership & Enrollment Forms

• Univera POS SelectOpen 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
• Adult Disabled Dependent FormOpen a PDF
• Classic Univera Traditional, Classic Univera Comprehensive, Univera PPO, Signature Series, & DentalOpen a PDF
• ActiveUniveraOpen a PDF
• Member Change Form for Direct Purchase PlansOpen a PDF
• valUcareOpen 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