Forms for Members
Use the links below to print/view copies of our most frequently used forms.
- Advance Care Planning - for health care proxies, living wills and more
- Manage Your Privacy
Prescription Claim Forms
- Prescription Drug Claim Form 2017 - Use for prescriptions that were purchased on or after Jan. 1, 2017.
- Prescription Drug Claim Form 2016 - - Use for prescriptions that were purchased during the year 2016.
Compound Prescription Drug Claim Form 2016
- Use for prescriptions that were purchased during the year 2016.
The Compound Prescription Drug Claim Form must also accompany the Prescription Drug Claim Form (enclosed) for all compound medications
- Dental Claim Form
- Medical Claim Form
- Surprise Bill Assignment of Benefits Form - Use this form if you receive a surprise bill for health care services.
Membership & Enrollment Forms
- Special Enrollment Attestation
- Univera POS Select
- Continuing Coverage for Students on Medical Leave Form
- Dental Coverage Attestation Form
- Dependent Certification Form
- Disabled Dependent Form
- Classic Univera Traditional, Classic Univera Comprehensive, Univera PPO, Signature Series, & Dental
- Member Change Form for Direct Purchase Plans
- Young Adult Option Certification Form
- Prior Coverage Verification Form
- Healthy New York Recertification