Member Forms

• Affidavit of Domestic Partnership
• Automated Payment Options
• Health Care Proxy
• New York State Out-of-Network Surprise Medical Bill Assignment of Benefits Form
• Student Dependent Verification Form (Dental Only)
• COBRA ARPA Eligibility Form

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

• HIPAA Form 2(A)
• HIPAA Form 2(D)
• HIPAA Form 2(e)
• Notice of Privacy Practices

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