Member Forms

• Drug Claim Form - Member
• 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
• NYS Out-of-Network Medical Bill Assignment of Benefits Form
• Student Dependent Verification Form
• Non-Medicare Subscriber Claim Form

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