Authorization

• Disclosure/Payment Forms, and Services Requiring Prior Authorization

  • Authorization to Disclose Information (PDF)
  • Authorization to Disclose Information—Spanish (PDF)
  • Prior Authorization (PDF)

  
  

Behavioral Health

• Behavioral Health Forms from Beacon Health Options

  • Authorization to Disclose Health Information (PDF)
  • Beacon Health Options Authorization to Disclose Health Information (PDF)
  • Mental Health/Substance Abuse Treatment Claim (Beacon Health Options) (PDF)

  
  

Claims & Reimbursement

• Claims & Reimbursement Forms

  • $125 Wellness Benefit Reimbursement Form (PDF)
  • Health Risk Screening Form (PDF)
  • Dental Claim Form (MVP Administered Dental) (PDF)
  • Dental Claim Form (Healthplex Standalone Dental Plans Only) (PDF)
  • Flexible Spending Account (FSA) Claim (PDF)
  • Health Reimbursement Account (HRA) Claim (PDF)
  • 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)

  
  

Enrollment/Change Forms

• Enrollment/Change Forms

  Download forms to enroll, make changes, or cancel a health plan subscriber.

  • Enrollment/Change Form—New York Individual (PDF)
  • Enrollment/Change Form—New York Large Group (PDF)
  • Enrollment/Change Form—New York Small Group HMO (PDF)
  • Enrollment/Change Form—New York Small Group EPO/PPO (PDF)
  • Dental Enrollment/Change Form—Individual (PDF)
  • Dental Enrollment/Change Form—Small Group (PDF)
  • Enrollment/Change Form—Vermont Individual (PDF)
  • Enrollment/Change Form—Vermont Group Plans (PDF)
  • One-Time Direct Debit Authorization Form (PDF) Download and complete this form to set up a one-time direct debit of your premium payment.

  
  

• Provider/PCP Change Forms

  • Provider Change and Patient Reassignment Request (PDF)

  
  

• Student Waiver Forms

  • Student Waiver Form: Out of Area Coverage – Medical (PDF)
  • Dental Plan Coverage Student Extension Application (PDF)

  
  

Miscellaneous

• Miscellaneous Forms

  • Diabetic Eye Exam Form (PDF)
  • Diabetic Eye Exam Form-Spanish (PDF)
  • Health Information Exchange (PDF)
  • Non Discrimination Complaint Intake Form
  • How to Read Your Explanation of Benefits (PDF)

  Un-cashed Checks?
  Please visit www.longlostmoney.com to see if MVP has any un-cashed checks in your name, or in the name of your business.

  • Unclaimed Property Claim Form (PDF)

  Advance Directives/Advance Care Planning – New York

  • Advance Directives What You Need to Know (PDF)
  • Directivas Avanzadas Lo Que Necesita Saber (PDF)
  • NYSBA Living Will and Health Care Proxy Forms

  Tax Forms

  • Health Coverage Tax Forms (1095-A, 1095-B, 1095-C)

  
  

Pharmacy

• Pharmacy Forms

  • CVS Caremark Mail Service Order Form (PDF)
  • CVS Caremark Prescription Reimbursement Claim Form (PDF)
  • Prescription Formulary Exception Request