Enrollment Forms, Applications, and Other Resources
Find forms for Large and Small Group, Individual, and Medicare plans, plus other common forms.
Common Broker Forms and Resources
- Authorization to Disclose Information
- Broker of Record for Individuals
- Broker of Record Letter
- MVP Spending Account Application
New York
Vermont
Group and Individual Plan Forms
See below for forms related to large group, small group, and individual plans.
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Large Group Plan Forms
- Employer Large Group Size Attestation
- Employer Large Group Size Attestation (Fillable)
- Large Group HMO Attestation
- Large Group HMO Attestation (Fillable)
New York Large Group
Vermont Large Group -
Small Group Plan Forms
- Attestation for Eligibility For Small Group Products
- Attestation for Eligibility For Small Group Products (Fillable)
- Grandfathered Plan Status Certification
- Grandfathered Plan Status Certification (Fillable)
New York Small Group- New York Small Group Application HMO
- New York Small Group Application EPO/PPO
- New York Small Group Recertification Form (Fillable)
- Enrollment/Change Form — New York Small Group HMO
- Enrollment/Change Form — New York Small Group EPO/PPO
Healthy New York- Healthy New York Small Group Application
- Healthy New York Small Group Recertification Form
- Healthy New York Small Group Recertification Form (Fillable)
- Enrollment/Change Form — Healthy New York
Vermont Small Group -
Individual Plan Forms
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Individual Medicare Plan Forms
See below for forms related to individual and employer group Medicare plans.
- Scope of Sales Appointment Confirmation Form (Static)
- Authorization to Disclose Information (ADI) Form
- Medicare Part D Comprehensive Formulary
- Plan Recommendation Tool
- Medicare Advantage Certification Course
Online Enrollment Tools
2023 Benefits at a Glance- Capital District/Central/Southern Tier Region
- Hudson Valley RegionMVP Medicare Secure Plus and Preferred Gold without Part D (HMO-POS)
- Rochester/Buffalo Region
- Optional Supplemental Dental Rider (All Regions)
Supplemental Benefit Information
2023 Summary of BenefitsCapital District/Central/Southern Tier Region Plans
- MVP Medicare Secure and Preferred Gold with Part D (HMO-POS)
- MVP Medicare WellSelect Plus with Part D (PPO)
Vermont and Northern New York Region Plans
- UVM Health Advantage Preferred, Secure, and Select with Part D (PPO)
- MVP Medicare Secure Plus and Preferred Gold without Part D (HMO-POS)
- MVP Medicare WellSelect with Part D (PPO)
Hudson Valley Region Plans
- MVP Medicare Secure Plus and Preferred Gold without Part D (HMO-POS)
- MVP Medicare WellSelect and WellSelect Plus with Part D (PPO)
- MVP Medicare Patriot Plan with Part D (PPO)
Rochester/Buffalo Plans
- MVP Medicare Secure, Preferred Gold with Part D, and Preferred Gold without Part D (HMO-POS)
- MVP® Medicare WellSelect® with Part D (PPO)
- MVP Medicare Patriot Plan with Part D (PPO)
Other
2023 Enrollment Applications
- Capital District/Central/Southern Tier Region
- Hudson Valley Region
- Rochester/Buffalo Region
- Vermont and Northern New York Region
- MVP DualAccess
- UVM Health Advantage
Medicare Star Ratings- MVP Medicare Secure (HMO-POS), MVP Medicare Secure Plus (HMO-POS), MVP Preferred Gold with Part D (HMO-POS), MVP Preferred Gold without Part D (HMO-POS), and MVP DualAccess (HMO D-SNP)
- MVP WellSelect with Part D (PPO), MVP WellSelect Plus with Part D (PPO), MVP Medicare Patriot Plan (PPO), UVM Health Advantage Preferred, Secure, and Select with Part D (PPO)
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Employer Group Medicare Plan Forms
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