Member Forms
Administrative
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Affidavit of Domestic Partnership
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Automated Payment Options
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Health Care Proxy
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New York State Out-of-Network Surprise Medical Bill Assignment of Benefits Form
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Student Dependent Verification Form (Dental Only)
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COBRA ARPA Eligibility Form
Claims
HIPAA (Health Insurance Portability and Accountability Act)
Pharmacy
- Coordination of Benefits Questionnaire - must be logged in to your online account to complete.
- Accident Inquiry Information Form - must be logged in to your online account to complete.
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