Medicaid Member Forms

From payment authorization forms to income declaration forms and more, find complete resources for Medicaid. En Espanol.

Medicaid

Download these helpful forms to manage your Medicaid coverage.
- Health Survey (PDF)
- Encuestra de Salud (PDF)
- Declaration of Support (PDF)
- Financial Maintenance Form (PDF)
- Financial Status Reporting for Farm or Business (PDF)
- Notice of Rights and Responsibilities for Support (PDF)
- Rental Income Declaration (PDF)
- Self-Declaration of Income (PDF)
- Verification of Employment (PDF)
- Authorization to Disclose Health Information (PDF)
- Authorization to Disclose Information — Spanish (PDF)

Mental Health Parity and Addiction Equity Act

MVP uses a team of clinical and compliance experts across the company to ensure continual compliance with the requirements of the Mental Health Parity and Addiction Equity Act (MHPAEA). MHPAEA is a federal law that prohibits insurance companies and managed care organizations from discriminating against individuals with mental health conditions (MH) or substance use disorders (SUD). MVP’s MHPAEA compliance program ensures that MVP uses financial requirements/quantitative treatment limits (FR/QTLs) and non-quantitative treatment limits (NQTLs) in a way that complies with parity. Parity requires each of these managed care practices to meet specific tests to assure that they are not being implemented in a discriminatory manner. MVP analyzes each FR/QTL/NQTL on an annual basis and updating the analysis as a part of any mid-year changes. Please contact MVP Member Services/Customer Care at the phone number listed on the back of your MVP Member ID card if you have any questions or concerns about MVP’s parity compliance.

Pharmacy

Pharmacy Forms
- CVS Caremark Mail Service Order Form (PDF)
- CVS Caremark Prescription Reimbursement Claim Form (PDF)

Advance Directives/Advance Care Planning – New York