Menu

Forms

General Broker Tools & Resources

Broker Forms
- Authorization to Disclose Information (PDF)
- Broker of Record for Individuals (PDF)
- Broker of Record Letter (PDF)
- 2019 NY Small Group Silver 4 Application (PDF)
- 2019 MVP Spending Account Application (PDF)
- 2020 NY Small Group Silver 4 Application (PDF)
- 2020 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 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)

Creditable Coverage

Medicare Broker Tools & Resources

Medicare Individual Broker Information
- Medicare Sales Materials Request (PDF) Note: Please download PDF before filling out and submitting form. Completing form in a browser window is unavailable at this time. We are working to fix the issue.
- Online Enrollment Tool
- Obtaining Certification 2020 Plan Year MVP Direct Bill (PDF)
- Scope of Sales Appointment Confirmation Form (PDF)
- Medicare Part D Comprehensive Part D Formulary
Benefits at a Glance
Supplemental Benefit Information
- Medicare WellBeing Rewards (PDF)
- SilverSneakers (PDF)
- TruHearing (PDF)
- Mom’s Meals (PDF)
Low Income Subsidy Premium Charts
Summary of Benefits
Enrollment Forms
Medicare Employer Group Broker Information