Print Forms
Claim Forms
To submit one of the following claim forms electronically or by mail, go to Submit Claims .
To submit a claim electronically, login and go to Submit Claims page.
- Medical or Vision Claim Form
- Prescription Drug Claim Form - Use for prescription drug reimbursement.
- Surprise Medical Bill Certification Form - Use this form if you receive a surprise bill for health care services.
- Dental Claim Form
- Dental Rewards Claim FormOpen a PDF
- Medical Claim FormOpen a PDF
- Prescription Drug Claim FormOpen a PDF - Use for prescription drug reimbursement.
- Surprise Bill Certification FormOpen a PDF - Use this form if you receive a surprise bill for health care services.
- Dental Claim FormOpen a PDF
FSA, HRA, and HSA Reimbursement Forms
- Reimbursement Account Forms (FSA/HRA/HSA) - Forms provided by Lifetime Benefit Solutions for Flexible Spending Account, Health Reimbursement Account, and Health Savings Account
General Forms
- Manage Your Privacy
- Manage Your Privacy
- Deluxe Item Upgrade FormOpen a PDF
- Dental Rewards Claim FormOpen a PDF
- New York Health Care Proxy form (PDF)Open a PDF
- New York Health Care Proxy form - Spanish (PDF)Open a PDF
Membership & Enrollment Forms
- Adult Disabled Dependent FormOpen a PDF
- Continuing Coverage for Students on Medical Leave Form Open a PDF
- Dental Coverage Attestation Form Open a PDF
- Dependent Certification FormOpen a PDF
- Medical Change Form for Direct Purchase PlansOpen a PDF
- Dental Change Form for Direct Purchase PlansOpen a PDF
- Young Adult Option Certification FormOpen a PDF - If your group renewal date has passed and you or your young adult is interested in the "Young Adult Option" use this form.
- Prior Coverage Verification FormOpen a PDF
- Healthy New York Recertification Open a PDF
Reimbursement Forms
Form 1095-B
Taxpayers are not required to include Form 1095-B when filing taxes and health insurers are no longer required to mail Form 1095-B to members.
If you would still like a copy, you can receive in a few different ways.
