Enrollment and HIPAA Forms
Becoming a member of SelectSaver HMO or SmartSaver RX PDP Value is easy. To enroll in the one of these plans, print off, complete and mail the application to:
HealthNow New York Inc.
PO Box 5204
Binghamton, NY 13905
Enrollment is generally for the full calendar year. Please refer to the Beneficiaries' and Plan's Rights and Responsibilities for information about disenrollment.
You may not disenroll or make changes at other times unless you meet certain special exceptions, such as if you move out of the plan's service area, qualify for Medicaid, or qualify for Extra Help with Medicare prescription drug costs.
Enrollment Forms and Information
- Direct Claim Form
Coordination of benefits / Direct claim form
- SelectSaver HMOPOS Application Form
Print off, complete and mail back to the address above.
- SmartSaver RX PDP Value Enrollment Application
- Solicitud de inscripción
Medicare beneficiaries may also enroll in SelectSaver HMO-POS or SmartSaver Rx PDP through the CMS Medicare Online Enrollment Center located at: http://www.medicare.gov
HIPAA Authorization Forms
In keeping with the HIPAA Privacy Regulations, the following forms should be used when you wish to give us permission to share your protected health information. See the HIPAA Privacy pages of this web site for further instructions.
- FORM 2(A), Authorization to use or disclose protected health information
Completion of this form, in most instances, is for the release of general health information - it does not allow for the release of HIV/AIDS, Mental Health, Alcohol or Substance Abuse information.
- FORM 2(D), Authorization for Release of HIV Information
Completion of this form will ONLY allow the release of HIV/AIDS information.
- 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.
- CMS Appointment of Representative Form
Instructions on how to appoint a representative. You can appoint a representative—like a family member, friend, advocate, attorney, doctor or someone else—to act on your behalf. Send this form to the same location where you are sending (or have already sent):, (1) your appeal if you are filing an appeal, (2) grievance if you are filing a grievance, or (3) initial determination or decision if you are requesting an initial determination or decision. If additional help is needed, contact us at 1-800-329-2792, TTY: 711.
We are open:
October 1 - February 14, 8 a.m. to 8 p.m., 7 days a week
February 15 - September 30, 8 a.m. to 8 p.m., Monday-Friday
This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change January 1 of each year. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. You must continue to pay your Medicare Part B Premium.
Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.
HealthNow New York Inc. is a Medicare Advantage and stand-alone PDP plan with a Medicare contract. Enrollment in HealthNow New York Inc. depends on contract renewal.
Content Last Updated January 19, 2016