Medicare Administrative and HIPAA Forms
Click below to view important administrative and HIPAA forms for your Medicare journey.
Administrative forms include coverage determination, drug claim forms, health care proxy form, appeal requests, and more.
HIPAA Authorization forms include HIPAA form 2(A), 2(D), 2(E) and the CMS appointment of representative form.
A division of HealthNow New York Inc., an independent licensee of the Blue Cross Blue Shield Association. BlueShield of Northeastern New York is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. This information is not a complete description of benefits. Call 1-800-329-2792 (TTY: 711) for more information. BlueShield of Northeastern New York complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-833-735-4515 (TTY: 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-833-735-4515 (TTY: 711).
Content Last Updated October 1, 2018