Forms for Members

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

Health-Related Forms

  • Advance Care PlanningOpen a PDF - for health care proxies, living wills and more
  • Manage Your PrivacyOpen a PDF

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
  • 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
  • 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
  • Prior Coverage Verification FormOpen a PDF
  • Healthy New York Recertification Open a PDF