Authorization Forms

Choose from the list below for disclosure forms and services requiring prior authorization:

• Authorization to Disclose Information
• Authorization to Disclose Information—Spanish
• One-Time Direct Debit Authorization
• Services that Require Prior Authorization—A Guide for Members

Behavioral Health Forms

Find forms relating to behavioral health below: 

• Authorization to Disclose Information
• Authorization to Disclose Information (Spanish)

Claims and Reimbursement Forms

Medical and Dental Forms 

Choose from the list below for forms relating to medical and dental claims and reimbursements:

• Claim Reimbursement Request Form
• Claim Reimbursement Request Form (Spanish)
• New York State Out-of-Network Surprise Medical Bill Assignment of Benefits Form
• Member Reimbursement Form for Doula Services
• Dental Claim Form (MVP Administered Dental)
• Dental Claim Form (Healthplex Standalone Dental Plans Only)

Spending Account Forms

Choose from the list below for forms relating to spending account claims: 

• 2025 Individual HSA Enrollment Packet
• Flexible Spending Account (FSA) Claim
• Health Reimbursement Account (HRA) Claim
• Lifestyle Spending Account (LSA) Claim
• Parking/Transit Flexible Spending Account Claim

Well-Being Forms

Choose from the list below for forms relating to well-being benefits:

• Well-Being Benefit Reimbursement Request (New York)
• Well-Being Benefit Reimbursement Request (Vermont Non-Standard)
• Well-Being Reward and Reimbursement Request for Essential Plan
• Health Risk Screening Form

Other Forms

Find additional forms below:

• MVP Commercial DME Non-Covered Items  

Enrollment/Change Forms

Choose from the list below to enroll, make changes, or cancel a health plan subscriber:

• Enrollment/Change Form—New York Individual
• Enrollment/Change Form—New York Individual (Spanish)
• Enrollment/Change Form—New York Small Group EPO/PPO
• Enrollment/Change Form—New York Small Group EPO/PPO (Spanish)
• Enrollment/Change Form—New York Large Group
• Enrollment/Change Form—New York Large Group (Spanish)
• Enrollment/Change Form Vermont Small Group
• Enrollment/Change Form Vermont Individual
• Enrollment/Change Form—Healthy New York
• Enrollment/Change Form—Healthy New York (Spanish)
• Enrollment/Change Form Student Plan
• Enrollment/Change Form Student Plan (Spanish)
• Enrollment/Change Form—New York Small Group HMO
• Enrollment/Change Form—New York Small Group HMO (Spanish)

Provider/Primary Care Provider Change Forms

Use the form below to change your primary care provider or for primary care providers to request reassignment of a patient: 

• Primary Care Provider Change or Patient Reassignment Request

Special Enrollment Period Forms

Use the form below if you are seeking to enroll in an individual insurance plan outside of the annual Open Enrollment period:

• New York Affidavit for Special Enrollment Period
• Vermont Affidavit for Special Enrollment Period

Student Forms

Choose from the list below to waive or request extension of student coverages:

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

Transition of Care 

Use the form below if you’ve just joined MVP and you need to transition the care of yourself or a covered spouse or dependent from a non-MVP physician:

• Transition of Care Benefits Application

Miscellaneous Forms

Choose from the list below for other forms relating to individual and family plans:

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

Uncashed Checks

Please visit the Long Lost Money website to see if we have any uncashed checks in your name or in the name of your business. If so, please fill out the below form to claim your property: 

• Unclaimed Property Claim Form

Advance Directives/Advance Care Planning–New York 

Choose from the list below for forms relating to advance directives, living wills, and health care proxies: 

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

Pharmacy Forms

Choose from the list below for forms relating to pharmacy benefits: 

• CVS Caremark Mail Service Order Form  
• CVS Caremark Mail Service Order Form (Spanish)
• CVS Caremark Prescription Reimbursement Claim Form  
• CVS Caremark Prescription Reimbursement Claim Form (Spanish) 
• CVS Caremark Over-the-Counter At-Home COVID-19 Test Reimbursement Form
• Pharmacy Prior Authorization Request Form
• Prescription Formulary Exception Request

Tax Forms

The IRS no longer requires taxpayers to provide the Form 1095-B with their taxes.

To view or download a copy of your form, sign in to  Gia® online and select Tax Documents from the top-right menu. 

To request that we mail you a copy, call our 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.

Visit the IRS website for forms relating to documentation of your health coverage at Health Coverage Tax Forms (1095-A, 1095-B, 1095-C).

If you have a Medicare plan, view our Medicare Forms and Resources page.

Medicaid Managed Care Member Guide

• Member Guide
• Guía de los Afiliados 

Common Medicaid and HARP Forms

• Health Survey
• Encuesta de Salud
• Declaration of Support
• Financial Maintenance Form
• Financial Status Reporting for Farm or Business
• Notice of Rights and Responsibilities for Support
• Rental Income Declaration
• Self-Declaration of Income
• Verification of Employment
• Authorization to Disclose Information
• Autorización para Revelar Información

Harmonious Health Care Plan Member Guide

• Member Guide
• Guía de los Afiliados

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. View guides to your Member ID card:

• Child Health Plus
• New York fully insured members
• Other members

Pharmacy

• Prescription Formulary Exception Request

Beginning April 1, 2023, all Medicaid members enrolled in MVP Medicaid Managed Care will receive their prescription drugs through NYRx, the Medicaid Pharmacy Program.

Information about the transition of the pharmacy benefit from MVP Medicaid Managed Care to NYRx, the Medicaid Pharmacy Program, can be found on health.ny.gov.

General information about NYRx, the Medicaid Pharmacy Program, can be found on health.ny.gov along with information for Members and Providers.

Advance Directives/Advance Care Planning–New York

Choose from the list below for forms relating to advance directives, living wills, and health care proxies: 

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

Child Health Plus Member Guide

• Member Guide
• Guía de los Afiliados

Common Child Health Plus (CHPlus) Forms

• Health Survey
• Encuesta de Salud
• Authorization to Disclose Information

Pharmacy 

Choose from the list below for forms relating to pharmacy benefits: 

• CVS Caremark Mail Service Order Form  
• CVS Caremark Prescription Reimbursement Claim Form  

Advance Directives/Advance Care Planning–New York 

Choose from the list below for forms relating to advance directives, living wills, and health care proxies: 

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