Member Enrollment/Change Form
Third Party Authorization Form
Third Party Authorization Form (Spanish)
Request for Health Information
Disability Eligibility Determination Form - PCP Version
Disability Eligibility Determination Form - Subscriber Version
MVP Non-Medical Pre Service Form
MVP Medical Pre Service Form
Student/Dependent Coverage Claim Form
NMHC RX Pharmacy Reimbursement Form [For dates of Service prior to 1/1/07]
College Student Waiver Form*
Healthy NY Re-certification Letter
MVP Dental Claim Form
Mail Order Prescription Order Form
Medco Direct Claim Form for Prescriptions
Medco Health, Allergy & Medication Questionnaire (HMQ)
Child Preparation Class Reimbursement Form
Medical Reimbursement Form
MVP Medical Questionnaire
Vermont Individual Indemnity Enrollment/Change Form

* Click here to submit a College Student Waiver online.

Looking for doctor appointment or check-up forms? Click here.

If you would prefer to have a form mailed to you, contact our Member Services department via e-mail or toll-free at 1-888-MVP-MBRS (1-888-687-6277).

Or write to us at:
MVP Health Care
Member Services Department
P.O. Box 2207
Schenectady, NY 12301