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)
  • Mental Health/Substance Abuse Treatment Claim (Beacon Health Options) (PDF)

  
  

Claims & Reimbursement

• Claims & Reimbursement Forms

  • $125 Wellness Benefit Reimbursement Form (PDF)
  • 2018 WellStyle Rewards Program – Health Risk Screening Form (PDF)
  • 2018 WellLife Rewards Program – Health Risk Screening Form (PDF)
  • 2018 VT Plus 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)
  • Healthy Lifestyle Riders Wellness Benefit Reimbursement Form (PDF)
  • Health Reimbursement Account (HRA) Claim (PDF)
  • Medical Claim Reimbursement Form (PDF)
  • New York State Out-of-Network Surprise Medical Bill Assignment of Benefits Form (PDF)
  • Student/Dependent Coverage Claim Form (PDF)

  
  

Enrollment/Change Forms

• 2019 Enrollment/Change Forms

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

  • 2019 Enrollment/Change Form—New York Individual (PDF)
  • 2019 Enrollment/Change Form—New York Large Group (PDF)
  • 2019 Enrollment/Change Form—New York Small Group HMO (PDF)
  • 2019 Enrollment/Change Form—New York Small Group EPO/PPO (PDF)
  • 2019 Enrollment/Change Form—Vermont Individual (PDF)
  • 2019 Enrollment/Change Form—Vermont Group Plans (PDF)

  
  

• 2018 Enrollment/Change Forms

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

  • 2018 Dental Enrollment/Change Form—Individual (PDF)
  • 2018 Dental Enrollment/Change Form—Small Group (PDF)
  • 2018 Enrollment/Change Form—NY Individual (PDF)
  • 2018 Enrollment/Change Form—NY Large Group (PDF)
  • 2018 Enrollment/Change Form—NY Small Group (PDF)
  • 2018 Enrollment/Change Form—VT Individual (PDF)
  • 2018 Enrollment/Change Form—VT Large Group (PDF)

  
  

• 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

  
  

Pharmacy

• Pharmacy Forms

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

  
  

Health Plans: Benefits at a Glance

• 2017 NY Individual Off-Exchange Plans

  Download regional summaries of benefits and rates for Individual Off-Exchange (Premier) plans. Rates effective January 1, 2017 – December 31, 2017.

  • 2017 NY Premier Individual Plans—Albany (Off) (PDF)
  • 2017 NY Premier Individual Plans—Buffalo (Off) (PDF)
  • 2017 NY Premier Individual Plans—Mid-Hudson (Off) (PDF)
  • 2017 NY Premier Individual Plans—New York City (Off) (PDF)
  • 2017 NY Premier Individual Plans—Rochester (Off) (PDF)
  • 2017 NY Premier Individual Plans—Syracuse (Off) (PDF)
  • 2017 NY Premier Individual Plans—Utica/Watertown (Off) (PDF)

  
  

• 2017 NY Individual On-Exchange Plans

  Download regional summaries of benefits and rates for Individual On-Exchange (Premier) plans. Rates effective January 1, 2017 – December 31, 2017.

  • 2017 NY Premier Individual Plans—Albany (On) (PDF)
  • 2017 NY Premier Individual Plans—Buffalo (On) (PDF)
  • 2017 NY Premier Individual Plans—Mid-Hudson (On) (PDF)
  • 2017 NY Premier Individual Plans—New York City (On) (PDF)
  • 2017 NY Premier Individual Plans—Rochester (On) (PDF)
  • 2017 NY Premier Individual Plans—Syracuse (On) (PDF)
  • 2017 NY Premier Individual Plans—Utica/Watertown (On) (PDF)

  
  

• 2017 VT Small Group and Individual Plans

  Download a summary of benefits and rates for Small Group and Individual plans. Rates effective January 1, 2017 – December 31, 2017.

  • 2017 Vermont Plans Product Placemat (PDF)

  
  

• 2018 NY Individual Off-Exchange Plans

  Download regional summaries of benefits and rates for Individual Off-Exchange (Premier & Premier Plus) plans. Rates effective January 1, 2018 – December 31, 2018.

  • 2018 NY Premier & Premier Plus Individual Plans—Albany (Off) (PDF)
  • 2018 NY Premier & Premier Plus Individual Plans—Buffalo (Off) (PDF)
  • 2018 NY Premier & Premier Plus Individual Plans—Mid-Hudson (Off) (PDF)
  • 2018 NY Premier & Premier Plus Individual Plans—New York City (Off) (PDF)
  • 2018 NY Premier & Premier Plus Individual Plans—Rochester (Off) (PDF)
  • 2018 NY Premier & Premier Plus Individual Plans—Syracuse (Off) (PDF)
  • 2018 NY Premier & Premier Plus Individual Plans—Utica/Watertown (Off) (PDF)

  
  

• 2018 NY Individual On-Exchange Plans

  Download regional summaries of benefits and rates for Individual On-Exchange (Premier & Premier Plus) plans. Rates effective January 1, 2018 – December 31, 2018.

  • 2018 NY Premier & Premier Plus Individual Plans—Albany (On) (PDF)
  • 2018 NY Premier & Premier Plus Individual Plans—Buffalo (On) (PDF)
  • 2018 NY Premier & Premier Plus Individual Plans—Mid-Hudson (On) (PDF)
  • 2018 NY Premier & Premier Plus Individual Plans—New York City (On) (PDF)
  • 2018 NY Premier & Premier Plus Individual Plans—Rochester (On) (PDF)
  • 2018 NY Premier & Premier Plus Individual Plans—Syracuse (On) (PDF)
  • 2018 NY Premier & Premier Plus Individual Plans—Utica/Watertown (On) (PDF)

  
  

• 2018 VT Small Group and Individual Plans

  • 2018 Vermont Plans Product Placemat (PDF)