Forms
General Broker Tools & Resources
Broker Forms
Large Group Information
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
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
- Authorization to Disclose Information (ADI) Form
- Medicare Part D Comprehensive Formulary
- MVP Medicare Cost Calculator
- Estimate MVP plan prescription prices and out-of-pocket costs
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 PlanSM
- 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
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