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

  • Authorization to Disclose Health Information (PDF)

  
  

Claims & Reimbursement

• Claims & Reimbursement Forms

  • 2020 Well-Being Benefit Reimbursement Request (New York) (PDF)
  • 2020 Well-Being Benefit Reimbursement Request (Vermont Non-Standard) (PDF)
  • 2019 Wellness Benefit Reimbursement Form (PDF)
  • Claim Reimbursement Request 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)
  • Health Risk Screening 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)

  
  

• Transition of Care

  • Transition of Care Benefits 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)

  
  

Tax Forms

• Form 1095-B

  The Internal Revenue Service (IRS) recently issued new guidelines for the Form 1095-B, which shows the months during the previous year a member received coverage. MVP will not mail the 2019 Form 1095-B to fully insured Large and Small Group subscribers, and to direct-enrolled Individual subscribers.

  Accessing Your Form 1095-B
  To view and download a copy now:

  • Sign in to your online member account and select Member Details.

  To request a copy be mailed:

  • Fill out this form with your MVP member information, or
  • Call MVP’s Customer Care Center at 1-855-853-4877, Monday through Friday from 8:30 am to 5 pm.

  If you need help filling out your tax return or have questions about how to file your taxes using Form 1095-B, you should contact a tax professional, or you can call the IRS Tax Help Line at 1-800-829-1040 or visit the IRS website.

  
  

Pharmacy

• Pharmacy Forms

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