Common Forms for MVP Members
From enrollment forms to claims and reimbursement—and everything in between—access the forms you need for your plan type.
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Individual and Family
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Medicare
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Medicaid
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Child Health Plus (CHPlus)
Authorization Forms
Choose from the list below for disclosure forms and services requiring prior authorization:
- Authorization to Disclose Information (PDF)
- Authorization to Disclose Information (PDF)—Spanish
- Services that Require Prior Authorization—A Guide for Members (PDF)
Behavioral Health Forms
Find forms relating to behavioral health below:
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 (PDF)
- New York State Out-of-Network Surprise Medical Bill Assignment of Benefits Form (PDF)
- Dental Claim Form (MVP Administered Dental) (PDF)
- Dental Claim Form (Healthplex Standalone Dental Plans Only) (PDF)
Spending Account Forms
Choose from the list below for forms relating to spending account claims:
- Flexible Spending Account (FSA) Claim (PDF)
- Health Reimbursement Account (HRA) Claim (PDF)
- Parking/Transit Flexible Spending Account Claim (PDF)
Well-Being Forms
Choose from the list below for forms relating to well-being benefits:
- Well-Being Benefit Reimbursement Request (New York) (PDF)
- Well-Being Benefit Reimbursement Request (Vermont Non-Standard) (PDF)
- Health Risk Screening Form (PDF)
Other Forms
Find additional forms below:
Enrollment/Change Forms
Choose from the list below to enroll, make changes, or cancel a health plan subscriber:
- Enrollment/Change Form—New York Individual (PDF)
- Enrollment/Change Form—New York Individual (PDF)—Spanish
- Enrollment/Change Form—New York Large Group (PDF)
- Enrollment/Change Form—New York Large Group (PDF)—Spanish
- Enrollment/Change Form—New York Small Group HMO (PDF)
- Enrollment/Change Form—New York Small Group HMO (PDF)—Spanish
- Enrollment/Change Form—New York Small Group EPO/PPO (PDF)
- Enrollment/Change Form—New York Small Group EPO/PPO (PDF)—Spanish
- Enrollment/Change Form—Healthy New York (PDF)
- Enrollment/Change Form—Healthy New York (PDF)—Spanish
- Enrollment/Change Form—Student Plan (PDF)
- Enrollment/Change Form—Student Plan (PDF)—Spanish
- Enrollment/Change Form—Vermont Individual (PDF)
- Enrollment/Change Form—Vermont Small Group (PDF)
- 2024 Individual HSA Enrollment Packet (PDF)
- 2023 Individual HSA Enrollment Packet (PDF)
- One-Time Direct Payment Plan Authorization (PDF)
- One-Time Direct Payment Plan Authorization (PDF)—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:
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:
Student Forms
Choose from the list below to waive or request extension of student coverages:
- Student Waiver Form: Out of Area Coverage – Medical (PDF)
- Dental Plan Coverage Student Extension Application (PDF)
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:
Miscellaneous Forms
Choose from the list below for other forms relating to individual and family plans:
- Diabetic Eye Exam Form (PDF)
- Diabetic Eye Exam Form (PDF)—Spanish
- Disability Eligibility Determination Form (PDF)
- Health Information Exchange (PDF)
- Non Discrimination Complaint Intake Form
- How to Read Your Explanation of Benefits (PDF)
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:
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 (PDF)
- Directivas Avanzadas: Lo Que Necesita Saber (PDF)
- 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 (PDF)
- CVS Caremark Mail Service Order Form (PDF)—Spanish
- CVS Caremark Prescription Reimbursement Claim Form (PDF)
- CVS Caremark Prescription Reimbursement Claim Form (PDF)—Spanish
- CVS Caremark Over-the-Counter At-Home COVID-19 Test Reimbursement Form (PDF)
- Pharmacy Prior Authorization Request Form (PDF)
- 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
Common Medicaid and HARP Forms
- 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 Information (PDF)
- Autorización para Revelar Información(PDF)
Harmonious Health Care Plan Member Guide
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:
Pharmacy
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:
Child Health Plus Member Guide
Common Child Health Plus (CHPlus) Forms
Pharmacy
Choose from the list below for forms relating to pharmacy benefits:
Advance Directives/Advance Care Planning–New York
Choose from the list below for forms relating to advance directives, living wills, and health care proxies:
Reach Out to Us
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