• Change Member ID
  or Product Name

Claims & Reimbursement

• Medical Claim Form

• Dental Claim Form
• TriVantage HMO/HealthDollars Reimbursement Form

Enrollment & Dependent

• Enrollment/Change Form
• Request for Coverage of Foster Dependent
• Handicapped Dependent Application
  

• COB Informational Form (Commercial)
• Healthy NY Individual & Sole Proprietor Application & Instructions
• Healthy NY Small Employers Application and Instructions

Behavioral Health - Value Options

• Behavioral Health Claim Form

• Behavioral Health Authorization to Disclose Form

Pharmacy

• the Medco Pharmacy Order Form (Commercial)
• Personal Medication List

• Medco Coordination of Benefits/Direct Claim Form (Commercial)

Information Release/Restriction

• Authorization to Disclose Information Form

• Health Care Proxy

Miscellaneous Forms

• Student Certification Form
• Out of Area Waiver

• Actively at Work