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Medical

Claims and reimbursement, records transfer, and more.
- 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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Pharmacy

Claims and reimbursement, records transfer, and more.
- 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.
- Davis Vision Out-of-Network Claim Form
  
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NYS Rate Filings
- 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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Other
- Affidavit Domestic Partnership
  
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- Health Care Proxy
  
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- Non-Medicare Subscriber Claim Form
  
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- New York State Out-of-Network Surprise Medical Bill Assignment of Benefits Form
  
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Highmark Blue Shield of Northeastern New York is a trade name of Highmark Western and Northeastern New York Inc., an independent licensee of the Blue Cross Blue Shield Association. Highmark Blue Shield of Northeastern New York serves residents and businesses in 13 counties in Northeastern New York.

References to “Highmark” are references to Highmark Inc., an independent licensee of the Blue Cross Blue Shield Association, and/or to one or more of its affiliated Blue companies.