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Forms


Finding the right HealthNow New York forms is easy. Just click on one of the categories below.


Forms for Members

Administrative Forms


Accessing Services for Autism Spectrum Disorder (ASD)


Affidavit of Domestic Partnership - Employer Group 

Legally establish a domestic partnership for the purposes of enrolling your partner on your health insurance plan.

Affidavit of Domestic Partnership - Individual

Legally establish a domestic partnership for the purposes of enrolling your partner on your health insurance plan.


Appeals Form

Complete this form to request an appeal.

Disability Certification Form
Certification of an unmarried child's disability and eligibility for continued coverage.


Drug Claim Form

Coordination of benefits / direct claim form.

Drug Mail Order Form

Pharmacy order form.


Drug Prior Authorization

Complete this form to request prior approval for non-formulary medications.

Gym Reimbursement Form

Only applicable to Platinum, Gold, Silver Standard, and Bronze individual products.

Gym Reimbursement Form - Featured

Only applicable to Featured individual plans.

Gym Reimbursement Form - Small Group

Only applicable to small group products, if your employer has 2 - 50 employees.

Health Care Proxy Form
Complete this New York State document to legally appoint someone you trust, such as a family member or close friend, as your healthcare agent; to make healthcare decisions for you if you lose the ability to make decisions for yourself.

Medicare Certification Form
This form is used to determine Medicare eligibility.

Student Dependent Verification Form

This form must be completed to verify that your dependent age 19 or over is a full-time student at an accredited College or University.

S
ubscriber Claim Form

Medical benefits subscriber claim form.


Vision Claim Form

EyeMed out-of-network claim form.


*Gym Reimbursement Forms - please reference your schedule of benefits to determine which form to download. Reimbursement levels may vary depending on your product.


HIPAA Authorization Forms

HIPAA Form 2(A) - Use/Disclose Protected Health Information
Completing this form permits release, in most instances, of general health information to the person(s) named in the form(s). This version does NOT allow for the release of HIV/AIDS, Mental Health, Alcohol or Substance Abuse information.

HIPAA Form 2(D)
Authorization for Release of HIV Information
Completion of this form will ONLY allow the release of HIV/AIDS information.

HIPAA Form 2(E)
Authorization for Release of Confidential Medical Records Related to Alcohol and Substance Abuse and Mental Health
Completion of this form will ONLY allow the release of Mental Health, Alcohol or Substance Abuse information.

Forms for Employers & Brokers

Administrative Forms

New Enrollment Application
SAMPLE FOR INSTRUCTIONAL USE ONLY - Not acceptable as a scannable enrollment application form.


Affidavit of Domestic Partnership

Legally establish a domestic partnership for the purposes of enrolling your partner on your health insurance plan.


Disability Certification Form

Certification of an unmarried child's disability and eligibility for continued coverage.


Medical Benefits Subscriber Claim Form

Medical benefits subscriber claim form.


Medicare Certification Form

This form is used to determine Medicare eligibility.

Provider Demographic Change Form
Please submit this form to our Corporate Provider File Department when adding additional office locations to your practice, or if your practice moves from its current location. Please fax the completed form to 716-887-8886.

Student Dependent Verification

This form must be completed to verify that your dependent age 19 or over is a full-time student at an accredited College or University.


HIPAA Authorization Forms

HIPAA Form 2(E)
Authorization for Release of Confidential Medical Records Related to Alcohol and Substance Abuse and Mental Health Completion of this form will ONLY allow the release of Mental Health, Alcohol orSubstance Abuse information.


HIPAA Form 2(D)
Authorization for Release of HIV Information Completion of this form will ONLY allow the release of HIV/AIDS information.


HIPAA Form 2(A) Use Disclose Protected Health Information
Completing this form permits release, in most instances, of general health information to the person(s) named in the form(s). This version does NOT allow for the release of HIV/AIDS, Mental Health, Alcohol or Substance Abuse information.