2018 Option Transfer Forms
(for current members changing plans)
|Form for Your Region||Counties in this Region|
|CNY PPO Option Transfer Form||Broome - Cayuga - Chemung - Chenango - Cortland - Jefferson - Lewis - Onondaga - Oswego - St. Lawrence - Schuyler - Steuben - Tioga - Tompkins|
|East PPO Option Transfer Form||Clinton - Delaware - Essex - Franklin - Fulton - Hamilton - Montgomery - Otsego|
|Rochester HMO Option Transfer Form||Livingston - Monroe - Ontario - Seneca - Wayne - Yates|
|Utica-Rome PPO Option Transfer Form||Herkimer - Madison - Oneida|
2018 Medicare Plan Applications
(for new enrollments)
Prescription Claim Forms
- Prescription Drug Claim Form 2017-2018 - Use for prescriptions that were purchased on or after Jan. 1, 2017.
- Compound Prescription Drug Claim Form - Use for prescriptions that were purchased during the year 2016. This form must accompany the Prescription Drug Claim Form for all compound medications.
- Prescription Drug Claim Form 2015-2016 - Use for prescriptions that were purchased during the years 2015-2016.
- Medical Claim Form
- 2018 Silver & Fit Claim Form - Use this form for out-of-network claims for plan year 2018.
- 2017 Silver & Fit Claim Form - Use this form for out-of-network claims for plan year 2017.
- Transplant Travel and Lodging Claim form
Dental Claim Form
We're committed to protecting your privacy
If you or a family member (age 18 or older) covered under your contract wish to designate another individual to receive information related to your health insurance and protected health information, please complete a disclosure authorization online or by using the forms below. An authorization form must be completed and returned to us for each person you or your family member wish to authorize.
Enter/Update Authorizations (requires login), or
Use these forms to Submit Authorizations by Mail:
- Authorization Release Form - In Spanish
- Answers to Frequently Asked Questions
- Release of Confidential HIV & Related Information
- Cancel an Authorization
- Confidentiality for Victims of Domestic Violence
Accessing Your Protected Health Information
Request a copy of your PHI to view or to request a change.
Request a list of instances your PHI was disclosed (with some exceptions).
Request that we communicate with you at an alternate address (if you are endangered).