Third Party Authorization Form
Third Party Authorization Form (Spanish)
Request for Health Information
Disability Eligibility Determination Form - PCP Version
Disability Eligibility Determination Form - Subscriber Version
College Student Waiver Form*
Healthy NY Re-certification Letter
MVP Dental Claim Form
Claim Reimbursement Form
Mail-Order Prescription Order Form
Medco Prescription Drug Reimbursement Form
Medco Health, Allergy & Medication Questionnaire (HMQ)
TriVantage EPO HealthDollar Credits Form
WebMD HealthDollar Rewards Reimbursement Form
NMHC RX Pharmacy Reimbursement Form [For dates of service prior to 1/1/07]

*Click here to submit a College Student Waiver online.

Looking for doctor appointment or check-up forms? Click here.

If you would prefer to have a form mailed to you, contact our Service Representative Department via e-mail or toll-free at 1-800-229-5851.

Or, if you are covered through one of the following employers, please call the service number listed below:

• Albany Medical Center plan participants: 1-800-361-4334
• IBM plan participants: 1-800-765-3773
• Golub Corporation plan participants:1-800-586-5386