Forms

General Broker Tools & Resources

• Broker Forms

  • Authorization to Disclose Information (PDF)
  • Broker of Record for Individuals (PDF)
  • Broker of Record Letter (PDF)
  • NY Small Group Silver 4 Application (PDF)
  • MVP Spending Account Application (PDF)

  
  

• Large Group Information

  • Enrollment/Change Form — New York Large Group (PDF)
  • Enrollment/Change Form — Vermont Group Plans (PDF)

  
  

• Small Group Information

  • New York Small Group Application HMO (PDF)
  • Enrollment/Change Form — New York Small Group HMO (PDF)
  • New York Small Group Application EPO/PPO (PDF)
  • Enrollment/Change Form — New York Small Group EPO/PPO (PDF)
  • Vermont Small Group Application Form (PDF)
  • Enrollment/Change Form — Vermont Group Plan (PDF)
  • New York Small Group Recertification Form (PDF)
  • Vermont Small Group Recertification Form (PDF)
  • Healthy New York Small Group Application (PDF)
  • Enrollment/Change Form — Healthy New York (PDF)
  • Vermont Small Group Plan Selection Form (PDF)

  
  

• Individual Information

  • Enrollment/Change Form — New York Individual (PDF)
  • Enrollment/Change Form — Vermont Individual (PDF)
  • Dental Enrollment/Change Form — Individual (PDF)
  • 2021 Individual HSA Enrollment Packet (PDF)
  • Unable to retrieve resource (PDF)

  
  

• Medicare Individual Broker Information

  • Medicare Sales Material Request (PDF)
  • Scope of Sales Appointment Confirmation Form (Fillable) (PDF)
  • Scope of Sales Appointment Confirmation Form (Static) (PDF)
  • Authorization to Disclose Information (ADI) Form (PDF)
  • Medicare Part D Comprehensive Formulary (PDF)
  • Plan Recommendation Tool

  Online Enrollment Tools

  • MVP Medicare Advantage and UVM Health Advantage plans
  • SmartFund MSA
  • MVP DualAccess (HMO D-SNP)

  Benefits at a Glance

  • Capital District/Central/Southern Tier Region (PDF)
  • Hudson Valley Region (PDF)
  • Rochester/Buffalo Region (PDF)
  • Vermont/Northern New York Region (PDF)
  • Optional Supplemental Dental Rider (All Regions) (PDF)

  MVP® Medicare Patriot Plan^SM

  • MVP Medicare Patriot Plan with Part D Brochure (PDF) – For residents of the following counties in New York: Albany, Allegany, Cattaraugus, Chautauqua, Dutchess, Erie, Genesee, Jefferson, Livingston, Monroe, Niagara, Oneida, Onondaga, Ontario, Orange, Orleans, Oswego, Putnam, Rensselaer, Rockland, Saratoga, Schenectady, Seneca, St.Lawrence, Steuben, Ulster, Wayne, Westchester, Wyoming, and Yates.

  UVM Health Advantage

  • UVM Health Advantage Brochure (PDF) – For residents of Vermont and Clinton, Essex, Franklin, Hamilton, and St. Lawrence counties in New York.

  Supplemental Benefit Information

  • WellBeing Rewards (PDF)
  • SilverSneakers (PDF)
  • Eyewear Allowance (PDF)
  • TruHearing (PDF)
  • Mom’s Meals (PDF)

  Benefits at a Glance

  • Capital District/Central/Southern Tier Region (PDF)
  • Hudson Valley Region (PDF)
  • Rochester/Buffalo Region (PDF)
  • Optional Supplemental Dental Rider (All Regions) (PDF)

  MVP® Medicare Patriot Plan^SM

  • MVP Medicare Patriot Plan with Part D Overview (PDF) – For residents of the following counties in New York: Albany, Allegany, Cattaraugus, Chautauqua, Dutchess, Erie, Genesee, Jefferson, Livingston, Monroe, Niagara, Oneida, Onondaga, Ontario, Orange, Orleans, Oswego, Putnam, Rensselaer, Rockland, Saratoga, Schenectady, Seneca, St.Lawrence, Steuben, Ulster, Wayne, Westchester, Wyoming, and Yates.

  UVM Health Advantage

  • UVM Health Advantage Brochure (PDF) – For residents of Vermont and Clinton, Essex, Franklin, Hamilton, and St. Lawrence counties in New York.

  Supplemental Benefit Information

  • WellBeing Rewards (PDF)
  • SilverSneakers (PDF)

  Summary of Benefits

  Capital District/Central/Southern Tier Region HMO-POS plans

  • MVP Medicare Secure and Preferred Gold with Part D (HMO-POS) (PDF)
  • MVP Medicare Secure Plus and Preferred Gold without Part D (HMO-POS) (PDF)
  • MVP Medicare WellSelect with Part D (PPO) (PDF)
  • MVP Medicare WellSelect Plus with Part D (PPO) (PDF)

  Vermont and Northern New York Region HMO-POS plans

  • UVM Health Advantage Preferred, Secure, and Select with Part D (PPO) (PDF)
  • MVP Medicare Secure Plus and Preferred Gold without Part D (HMO-POS) (PDF)
  • MVP Medicare WellSelect with Part D (PPO) (PDF)

  Hudson Valley Region plans

  • MVP Medicare Secure and Preferred Gold with Part D (HMO-POS) (PDF)
  • MVP Medicare Secure Plus and Preferred Gold without Part D (HMO-POS) (PDF)
  • MVP Medicare WellSelect and WellSelect Plus with Part D (PPO) (PDF)

  Rochester/Buffalo Region Plans

  • MVP Medicare Secure, Preferred Gold with Part D, and Preferred Gold without Part D (HMO-POS) (PDF)
  • MVP® Medicare WellSelect® with Part D (PPO) (PDF)

  MVP Medicare Patriot Plan PPO (PDF)

  MVP DualAccess (HMO D-SNP) (PDF)

  SmartFund MSA (PDF)

  Enrollment Applications

  • Capital District/Central/Southern Tier Region (PDF)
  • Hudson Valley Region (PDF)
  • Rochester/Buffalo Region (PDF)
  • Vermont and Northern New York Region (PDF)
  • MVP Medicare Patriot Plan (PDF)
  • MVP DualAccess (PDF)

  Medicare Star Ratings

  • MVP GoldValue with Part D (HMO-POS), MVP GoldSecure with Part D (HMO-POS), and MVP Preferred Gold with and without Part D (HMO-POS) (PDF)
  • MVP Gold PPO with Part D (PPO) and MVP® WellSelect® with Part D (PPO) (PDF)
  • MVP® SmartFund MSA^™ (PDF)

  
  

• Medicare Employer Group Broker Information

  • Medicare Advantage Employer Handbook (PDF)
  • Medicare Advantage Certification Course (PDF)
  • Medicare Broker of Record Letter (PDF)
  • Medicare Group Comprehensive Part D Formulary
  • Medicare Advantage Certification Course (PDF)