Forms for Members
Use the links below to print/view copies of our most frequently used 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.
- 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