Member Forms

• Drug Claim Form - Members
• Drug Mail Order Form - Member

• EyeMed Out-of-Network Claim Form
• Subscriber Claim Form

• HIPAA Form2(a)
• HIPAA Form2(d)
• HIPAA Form2(e)

• Affidavit Domestic Partnership
• Automated Payment Option
• Health Care Proxy
• Student Dependent Verification Form
• Non-Medicare Subscriber Claim Form
• New York State Out-of-Network Surprise Medical Bill Assignment of Benefits Form

• Accessing Services for Autism Spectrum Disorder (ASD)
• Disability Certification Form