Member Forms

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

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

• HIPAA 2D - Authorization for Release of HIV Information
• HIPAA 2E - Authorization for Release of Confidential Medical Records Related to Alcohol and Substance Abuse
• HIPAA 2A 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