Member Forms

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

• EyeMed Out of Network Claim Form
• Subscriber Claim Form

• HIPAA Form2(a)
• HIPAA Form2(d)
• HIPAA Form 2(e)
• Notice of Privacy Practices_WNY_v1.indd

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