Broker Registration Forms
Choose the form that best fits your role. Whether you're an individual broker or represent an agency, select the appropriate option below to get started.
Medicare
- Individual + Agency Broker Form
- New Agency Form
Commercial
If you’re looking to sell our commercial products, please email us at brokercustomerservice@mvphealthcare.com along with the following:
- Current Agency License — Required for agency appointment, if applicable.
- Current Individual Broker's License — Required for broker Appointment.
- Current E&O Certificate — MVP requires a minimum of $1,000,000 coverage.
- W9
- MVP will then review your documents and send you a request for any additional documentation needed.
Broker Forms and Resources
- Authorization to Disclose Information
- Broker of Record for Individuals
- Broker of Record Letter
- Health Benefits Administrator and Plan Sponsor Designation
Plan Selection Forms
Group and Individual Plan Forms
See below for forms related to large group, small group, and individual plans.
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- Employer Large Group Size Attestation
- Employer Large Group Size Attestation (Fillable)
- Grandfathered Plan Status Certification
- Grandfathered Plan Status Certification (Fillable)
- Independent Contractor Attestation
- Independent Contractor Attestation (Fillable)
- Large Group HMO Attestation
- Large Group HMO Attestation (Fillable)
New York Large Group
- Enrollment/Change Form—New York Large Group
- Enrollment/Change Form—New York Large Group—Spanish
- New York Large Group Billing and Contact Form
Vermont Large Group
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- Affidavit of Group Sponsored Coverage for Common Law Employees
- Affidavit of Group Sponsored Coverage for Common Law Employees (Fillable)
- Attestation for Eligibility For Small Group Products
- Attestation for Eligibility For Small Group Products (Fillable)
- Grandfathered Plan Status Certification
- Grandfathered Plan Status Certification (Fillable)
- Independent Contractor Attestation
- Independent Contractor Attestation (Fillable)
New York Small Group
- Enrollment/Change Form—New York Small Group HMO
- Enrollment/Change Form—New York Small Group HMO —Spanish
- Enrollment/Change Form—New York Small Group EPO/PPO
- Enrollment/Change Form—New York Small Group EPO/PPO—Spanish
- New York Small Group Application HMO (Fillable)
- New York Small Group Application EPO/PPO (Fillable)
- New York Small Group Recertification Form
- New York Small Group Recertification Form (Fillable)
Healthy New York
- Enrollment Change Form Healthy New York
- Enrollment/Change Form Healthy NY - Spanish
- Healthy New York Small Group Application
- Healthy New York Small Group Application (Fillable)
- Healthy New York Small Group Recertification Form
- Healthy New York Small Group Recertification Form (Fillable)
Vermont Small Group
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See below for forms related to individual and employer group Medicare plans.
- Authorization to Disclose Information (ADI) Form
- Medicare Part D Comprehensive Formulary
- Medicare Advantage Certification Course
- Plan Recommendation Tool
- Scope of Sales Appointment Confirmation Form
Online Enrollment Tools
Plan Year 2025
Benefits at a Glance
Summary of Benefits
- Capital District, Southern Tier, Hudson Valley, Central New York
- Hudson Valley
- Rochester/Buffalo
- DualAccess
Enrollment Applications
Medicare Star Ratings
- MVP Medicare Secure (HMO-POS), MVP Medicare Secure Plus (HMO-POS), MVP Preferred Gold with Part D (HMO-POS), MVP Preferred Gold without Part D (HMO-POS), and MVP DualAccess (HMO D-SNP)
- MVP WellSelect with Part D (PPO), MVP WellSelect Plus with Part D (PPO), MVP Medicare Patriot Plan (PPO), UVM Health Advantage Preferred, Secure, and Select with Part D (PPO)
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