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.
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. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or coinsurance may change January 1 of each year. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.You must continue to pay your Medicare Part B Premium.Out-of-network/non-contracted providers are under no obligation to treat BlueShield of Northeastern New York members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next. A division of HealthNow New York Inc., an independent licensee of the BlueCross BlueShield Association. A salesperson will be present with information and applications. For accommodations of persons with special needs at sales meetings, please call 1-800-258-7453 (TTY 711). 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 June 18, 2018