2019 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 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

2019 Medicare Plan Applications

(for new enrollments)

Plan Application for Region in these Counties
Medicare BlueBasic PPO, Medicare BlueClassic PPO, Medicare BlueSecure PPO, Medicare BlueEnhanced PPO, Medicare BlueEssential PPO CNY Broome - Cayuga - Chemung - Chenango - Cortland - Jefferson - Lewis - Onondaga - Oswego - St. Lawrence - Schuyler - Steuben - Tioga - Tompkins
Medicare BlueBasic PPO, Medicare BluePlus PPO East Clinton - Delaware - Essex - Franklin - Fulton - Hamilton - Montgomery - Otsego
Medicare Bassett HMO East Delaware - Otsego
Medicare Blue Choice Value HMO, Medicare Blue Choice Value Plus HMO, Medicare Blue Choice Optimum HMO-POS, Medicare Blue Choice Platinum HMO-POS, Medicare Blue Choice Select HMO-POS Rochester Livingston - Monroe - Ontario - Seneca - Wayne - Yates
Medicare BlueBasic PPO, Medicare BlueClassic PPO, Medicare BlueSecure PPO, Medicare BlueEnhanced PPO, Medicare BlueEssential PPO Utica-Rome Madison - Oneida
Medicare BlueBasic PPO, Medicare BlueClassic PPO, Medicare BlueSecure PPO, Medicare BlueEnhanced PPO, Medicare BlueEssential PPO, Medicare Bassett HMO Utica-Rome Herkimer

2018 Medicare Plan Applications

(for new enrollments)

Plan Application for Region in these Counties
Medicare BlueBasic PPO, Medicare BlueClassic PPO, Medicare BlueSecure PPO, Medicare BlueEnhanced PPO, Medicare BlueEssential PPO CNY Broome - Cayuga - Chemung - Chenango - Cortland - Jefferson - Lewis - Onondaga - Oswego - St. Lawrence - Schuyler - Steuben - Tioga - Tompkins
Medicare BlueBasic PPO, Medicare BluePlus PPO East Clinton - Delaware - Essex - Franklin - Fulton - Hamilton - Montgomery - Otsego
Medicare Bassett HMO East Delaware - Otsego
Medicare Blue Choice Value HMO, Medicare Blue Choice Value Plus HMO, Medicare Blue Choice Optimum HMO-POS, Medicare Blue Choice Platinum HMO-POS, Medicare Blue Choice Select HMO-POS Rochester Livingston - Monroe - Ontario - Seneca - Wayne - Yates
Medicare BlueBasic PPO, Medicare BlueClassic PPO, Medicare BlueSecure PPO, Medicare BlueEnhanced PPO, Medicare BlueEssential PPO Utica-Rome Madison - Oneida
Medicare BlueBasic PPO, Medicare BlueClassic PPO, Medicare BlueSecure PPO, Medicare BlueEnhanced PPO, Medicare BlueEssential PPO, Medicare Bassett HMO Utica-Rome Herkimer

Prescription Claim Forms

Claim Forms

Other Forms

Privacy Forms

We will not disclose information to another person unless we are required or permitted to do so by law. Privacy laws prohibit us from disclosing protected health information (PHI) related to your health insurance coverage to another person or organization (with some exceptions, like your physician) without your written authorization. If you would like us to communicate with someone contacting us on your behalf (spouse, parent, child, friend, etc.), please complete the authorization release form. Our Notice of Privacy Practices describes other exceptions that may apply.

Authorization to Disclose Protected Health Information (PHI)

If you or a family member (age 18 or older, or for certain medical conditions under age 18) 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

Obtaining Your Designated Record Set (DRS)

A designated record set (DRS) are records we maintain and use to make decisions about your healthcare coverage. You have the right to inspect and obtain a copy, or request that we amend your protected health information. Additionally, you can request an Accounting of Disclosure. The list contains instances where your PHI was disclosed for purposes other than payment, treatment, or healthcare operations.

Confidential Communications/Victims of Domestic Violence

You have the right to request to receive communications at an alternative location if disclosure of such information would endanger your safety or your child’s safety. If you would like to request confidential communications, please complete the Confidential Communications Request form below.

Additionally, per NY Insurance Law §2612, if we receive a copy of a valid order of protection against the policyholder of the policy under which you are covered, or against another person covered under the same group policy that you are, we will not, for the duration of the order, disclose to that person your address or phone number, or the address or phone number of your providers. For more information, see NY Insurance Law §2612.

If you have previously completed this form and wish to revoke it, please contact Customer Services at the phone number on your member identification card.

Victims of Domestic and Sexual Violence can contact the NYS Domestic and Sexual Violence Hotline at 1-800-942-6906.

For more information about our Privacy Practices, call Customer Services at the phone number printed on your Member Card. Follow this link to File a Complaint about Our Privacy Practices.

Excellus BlueCross BlueShield contracts with the Federal Government and is an HMO plan and PPO plan with a Medicare contract. Enrollment in Excellus BlueCross BlueShield depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. .
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