Behavioral Health Forms
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)
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
Student Waiver Forms
Transition of Care
- 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)
Please visit longlostmoney.com to see if MVP has any un-cashed checks in your name, or in the name of your business.
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
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.