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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. 

 

Medicare Questions?

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1-833-735-4512 (TTY 711)
Oct. 1 - March 31, 8 a.m. - 8 p.m., 7 days a week
April 1 - Sept. 30, 8 a.m. - 8 p.m., Monday - Friday

Highmark Blue Shield of Northeastern New York (Highmark BSNENY) is a trade name of Highmark Western and Northeastern New York Inc., an independent licensee of the Blue Cross Blue Shield Association. Highmark BSNENY is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. Highmark BSNENY 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).

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Content last updated: October 1, 2021