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  • Prescription Claim Forms
  • Prescription Drug Claim FormOpen a PDF - Use for prescriptions that were purchased on or after Jan. 1, 2017.
  • Claim Forms
  • $300 Univera Fit Dollars Reimbursement FormOpen a PDF
  • $300 ActiveRewards Reimbursement Claim FormOpen a PDF
  • Medical Claim FormOpen a PDF
  • Dental Claim FormOpen a PDF
  • Medical & Dental Enrollment Forms for Groups with 101+ Employees
  • ActiveUniveraOpen a PDF
  • ActiveUnivera HDHPOpen a PDF
  • valUcareOpen a PDF
  • valUcare HDHPOpen a PDF
  • Univera POS SelectOpen a PDF
  • Classic Univera Traditional, Classic Univera Comprehensive, Univera PPO, Signature Series, & DentalOpen a PDF
  • Signature Series CopayOpen a PDF
  • Signature Series HDHPOpen a PDF
  • Signature Series HybridOpen a PDF
  • Eligibility Certification Forms
  • Continuing Coverage for Students on Medical Leave Form Open a PDF
  • Dependent Certification FormOpen a PDF
  • Domestic Partner Affidavit FormOpen a PDF
  • Disabled Dependent FormOpen a PDF
  • Qualified Medical Child Support Order Certification FormOpen a PDF
  • Qualified Medical Child Support Order Disenrollment FormOpen a PDF
  • Young Adult Option Certification FormOpen a PDF
  • Healthy New York Recertification Open a PDF
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