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

  • Together We Grow Brochure (PDF)
  • New York Large Group Billing & Contact Form (PDF)
  • Enrollment/Change Form—New York Large Group (PDF)
  • Enrollment/Change Form—Vermont Group Plans (PDF)
  • MVP Core Analytics (PDF)

  
  

• Small Group Information

  • Small Group Management Center Quick Reference Guide (PDF)
  • Together We Grow Brochure (PDF)
  • 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 (PDF)
  • Vermont Group Plan Enrollment Form (PDF)
  • New York Small Group Recertification Form (PDF)
  • Vermont Small Group Recertification Form (PDF)
  • Healthy New York Small Group Application (PDF)
  • Healthy New York Recertification Form (PDF)

  
  

• Individual Information

  • Together We Grow Brochure (PDF)
  • Enrollment/Change Form—New York Individual (PDF)
  • Enrollment/Change Form—Vermont Individual (PDF)
  • Dental Enrollment/Change Form – Individual (PDF)
  • Individual HSA Enrollment Form (PDF)

  
  

• Medicare Individual Broker Information

  • Medicare Sales Material Request – To complete this form, please download and save it to your computer. Email completed forms to mvpmedicarebrokers@mvphealthcare.com. Forms cannot be completed in a web browser window.
  • Online Enrollment Tool
  • Scope of Sales Appointment Confirmation Form (Fillable)
  • Scope of Sales Appointment Confirmation Form (Static)
  • Authorization to Disclose Information (ADI) Form
  • Medicare Part D Comprehensive Formulary
  • Plan Recommendation Tool

  Benefits at a Glance

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

  MVP® Medicare Patriot Plan^SM

  • MVP Medicare Patriot Plan with Part D Overview – For residents of the following counties in New York: Albany, Cattaraugus, Chautauqua, Dutchess, Erie, Jefferson, Monroe, Niagara, Oneida, Onondaga, Ontario, Oswego, Rensselaer, Saratoga, Schenectady, Steuben, St. Lawrence, Ulster, and Wayne.

  Supplemental Benefit Information

  • WellBeing Rewards
  • SilverSneakers
  • TruHearing
  • Mom’s Meals
  • Over-the-counter Allowance

  Summary of Benefits

  • Capital District/Central/Southern Tier Regions HMO-POS plans
  • Capital District/Central/Southern Tier Regions PPO plans
  • Hudson Valley Region HMO-POS plans
  • Hudson Valley Region PPO plans
  • Rochester/Buffalo HMO-POS plans
  • Rochester/Buffalo PPO plans
  • MVP Medicare Patriot Plan PPO

  Low Income Subsidy Premium Charts

  • Capital District/Southern Tier Region
  • Central New York Region
  • Hudson Valley Region
  • Rochester/Buffalo Region
  • Vermont Region
  • MVP Medicare Patriot Plan

  Enrollment Applications

  • Capital District/Central/Southern Tier/Vermont Region
  • Hudson Valley Region
  • Rochester/Buffalo Region
  • MVP Medicare Patriot Plan

  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)
  • MVP Gold PPO with Part D (PPO) and MVP® WellSelect® with Part D (PPO)
  • MVP® SmartFund MSA^™

  
  

• 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)