Member Forms

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

• EyeMed Out of Network Claim Form
• Subscriber Claim Form

• HIPAA Form2(a)
• HIPAA Form2(d)
• Notice of Privacy Practices
• HIPAA Form2(e)

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

• Disability Certification Form