2019 Medicare Plan Application
Prescription Claim Forms
- Prescription Drug Claim Form 2017-2019 - Use for prescriptions that were purchased on or after Jan. 1, 2017.
- Compound Prescription Drug Claim Form - Use for prescriptions that were purchased during the years 2015-2016. This form must accompany the Prescription Drug Claim Form for all compound medications.
- Prescription Drug Claim Form 2015-2016 - Use for prescriptions that were purchased during the years 2015-2016.
- Medical Claim Form
- 2019 Silver & Fit Claim Form - Use this form for out-of-network claims for plan year 2019.
- 2018 Silver & Fit Claim Form - Use this form for out-of-network claims for plan year 2018.
- Transplant Travel and Lodging Claim form
Dental Claim Form
Authorization to Disclose Protected Health Information (PHI)
If you or a family member (age 18 or older, or for certain medical conditions under age 18) covered under your contract wish to designate another individual to receive information related to your health insurance and protected health information, please complete a disclosure authorization online or by using the forms below. An authorization form must be completed and returned to us for each person you or your family member wish to authorize.
Use these forms to Submit Authorizations by Mail:
- Authorization Release Form (English)
- Authorization Release Form (Spanish)
- Answers to Frequently Asked Questions
- Release of Confidential HIV & Related Information
- Cancel an Authorization
Obtaining Your Designated Record Set (DRS)
A designated record set (DRS) are records we maintain and use to make decisions about your healthcare coverage. You have the right to inspect and obtain a copy, or request that we amend your protected health information. Additionally, you can request an Accounting of Disclosure. The list contains instances where your PHI was disclosed for purposes other than payment, treatment, or healthcare operations.
Confidential Communications/Victims of Domestic Violence
You have the right to request to receive communications at an alternative location if disclosure of such information would endanger your safety or your child’s safety. If you would like to request confidential communications, please complete the Confidential Communications Request form below.
Additionally, per NY Insurance Law §2612, if we receive a copy of a valid order of protection against the policyholder of the policy under which you are covered, or against another person covered under the same group policy that you are, we will not, for the duration of the order, disclose to that person your address or phone number, or the address or phone number of your providers. For more information, see NY Insurance Law §2612.
If you have previously completed this form and wish to revoke it, please contact Customer Services at the phone number on your member identification card.
Victims of Domestic and Sexual Violence can contact the NYS Domestic and Sexual Violence Hotline at 1-800-942-6906.
For more information about our Privacy Practices, call Customer Services at the phone number printed on your Member Card. Follow this link to File a Complaint about Our Privacy PracticesOpen a PDF.