Member Forms

• Drug Mail Order Form - Express Scripts
• Drug Claim Form - Member

• Davis Vision Out-of-Network Claim Form
• Subscriber Claim Form

• Affidavit of Domestic Partnership
• Automated Payment Options
• Health Care Proxy- Appointing Your Health Care Agent in New York State
• New York State Out-of-Network Surprise Medical Bill Assignment of Benefits Form
• Student Dependent Verification Form