Authorization

• Disclosure/Payment Forms, and Services Requiring Prior Authorization

  • Authorization to Disclose Information (PDF)
  • Authorization to Disclose Information – Spanish (PDF)
  • Services that Require Prior Authorization – A Guide for Members (PDF)

  
  

Behavioral Health

• Behavioral Health Forms

  
  

Claims & Reimbursement

• Claims & Reimbursement Forms

  Medical & Dental Forms

  • Claim Reimbursement Request Form (PDF)
  • Medicare Reimbursement Account Claim Form (PDF) (for Federal Employee Health Benefit Plan only)
  • New York State Out-of-Network Surprise Medical Bill Assignment of Benefits Form (PDF)
  • Dental Claim Form (MVP Administered Dental) (PDF)
  • Dental Claim Form (Healthplex Standalone Dental Plans Only) (PDF)

  Spending Account Forms

  • Flexible Spending Account (FSA) Claim (PDF)
  • Health Reimbursement Account (HRA) Claim (PDF)
  • Parking/Transit Flexible Spending Account Claim (PDF)

  Well-Being Forms

  • Well-Being Benefit Reimbursement Request (New York) (PDF)
  • Well-Being Benefit Reimbursement Request (Vermont Non-Standard) (PDF)
  • Health Risk Screening Form

  Other

  • MVP Commercial DME Non-Covered Items (PDF)

  
  

Enrollment/Change Forms

• Enrollment/Change Forms

  
  

• Provider/PCP Change Forms

  
  

• Student Waiver Forms

  
  

• Transition of Care

  
  

Miscellaneous

• Miscellaneous Forms

  
  

Tax Forms

• Form 1095-B

  
  

Pharmacy

• Pharmacy Forms