• Change Member ID
  or Product Name

Claims & Reimbursement

• Student/Dependent Coverage Claim Form
• Medical Reimbursement Form
• TriVantage EPO Lifestyle Credit Reimbursement

• MVP Dental Claim Form
• Child Preparation Class Reimbursement
• New Hampshire Health First Wellness Verification

   

Enrollment & Dependent

• Member Enrollment/Change Form
• NH Member Enrollment/Change Form
• Disability Eligibility Determination Form - PCP
• Disability Eligibility Determination Form - Subscriber
  

• Healthy NY Re-certification Letter
• Vermont Individual Indemnity Enrollment/Change
• College Student Waiver Form*
• MVP Medical Questionnaire

Authorization & Referral

• Request for Health Information
• Member Formulary Exception (log-in required)

• Medication Prior Authorization

Pharmacy

• Mail Order Prescription Order Form
• Medco Prescription Drug Reimbursement Form

• Medco Health, Allergy & Medication Questionnaire
• Personal Medication List

Information Release/Restriction

• Authorization to Disclose Information Form