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Medical
Claims and reimbursement, records transfer, and more.
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Coordination of Benefits
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Authorization to Use or Disclose Protected Health Information (PHI) - HIPAA Form2(a)
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New York State Required Authorization for Release of Confidential HIV-Related Information - HIPAA Form2(d)
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Authorization For Release of Confidential PHI - HIPAA Form2(e)
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Notice of Privacy Practices
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Non-Medicare Subscriber Claim Form
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Pharmacy
Claims and reimbursement, records transfer, and more.
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Home Delivery Order Form (A)
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Prescription Drug Medication Request Form
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Prescription Drug Reimbursement Form
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Specialty Drug Request Form
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Vision
Claims and reimbursement, records transfer, and more.
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Davis Vision Out-of-Network Claim Form
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Dental
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Dental Claims Form
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Student Verification Form
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NYS Rate Filings
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2023 Individual and Family Premium Rate Change
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2023 Individual and Family Product NYS Exhibit
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2023 Small Group Employer Premium Rate Change
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2023 Small Group Employer Coverage NYS Exhibit
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2024 Individual and Family Premium Rate Change
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2024 Small Group Employer Premium Rate Change
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2024 Small Group Employer Coverage NYS Exhibit
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2024 Individual and Family Product NYS Exhibit
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2024 Medigap Individual Premium Rate Change
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2024 Medigap Group Premium Rate Change
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Other
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Affidavit Domestic Partnership
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Health Care Proxy
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New York State Out-of-Network Surprise Medical Bill Assignment of Benefits Form
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Cultural and Language Resource
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HIV Resource
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Overview of the Quality Improvement Program
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