Authorization

  • Disclosure/Payment Forms, and Services Requiring Prior Authorization

    • Authorization to Disclose Information

      Description to come

      Download
    • Authorization to Disclose Information—Spanish Download
    • Direct Payment Authorization

      Description to come

      Download
    • El Programa de Pago Directo de MVP

      Description to come

      Download
    • Prior Authorization Download


Behavioral Health

  • Behavioral Health Forms from Beacon Health Options

    • Authorization to Disclose Health Information (Beacon Health Options) Download
    • Mental Health/Substance Abuse Treatment Claim (Beacon Health Options) Download


Claims & Reimbursement

  • Claims & Reimbursement Forms

    • Medical Claim Reimbursement Form Download
    • Dental Claim Form (American Dental Association) Download
    • Dental Claim Form (Healthplex) Download
    • Flexible Spending Account (FSA) Claim Download
    • Health Reimbursement Account (HRA) Claim Download
    • Student/Dependent Coverage Claim Form Download
    • Child Preparation Reimbursement Download
    • New York State Out-of-Network Surprise Medical Bill Assignment of Benefits Form Download
    • $125 Wellness Benefit Reimbursement Form Download
    • TriVantage Wellness Benefit Reimbursement Form Download
    • Healthy Lifestyle Riders Wellness Benefit Reimbursement Form Download
    • 2017 WellStyle Rewards Program – Health Risk Screening Form Download
    • 2017 WellLife Rewards Program – Health Risk Screening Form Download
    • 2017 VT Plus Health Risk Screening Form Download


Enrollment Change Forms

  • 2017 Enrollment/Change Forms

    Download forms to enroll, make changes or cancel a health plan subscriber.

    • 2017 Dental Enrollment/Change Form—Individual Download
    • 2017 Dental Enrollment/Change Form—Small Group Download
    • 2017 Enrollment/Change Form—NY Individual Download
    • 2017 Enrollment/Change Form—NY Large Group Download
    • 2017 Enrollment/Change Form—NY Small Group Download
    • 2017 Enrollment/Change Form—VT Individual Download
    • 2017 Enrollment/Change Form—VT Large Group Download
    • 2017 Enrollment Instructions—NY Individual Download


  • 2016 Enrollment/Change Forms

    Download forms to enroll, make changes or cancel a health plan subscriber.

    • 2016 Dental Enrollment/Change Form—Individual Download
    • 2016 Dental Enrollment/Change Form—Small Group Download
    • 2016 Enrollment/Change Form—NY Individual Download
    • 2016 Enrollment/Change Form—NY Large Group

      Enroll, change, or cancel health plan for NY subscribers

      Download
    • 2016 Enrollment/Change Form—NY Small Group

      Enroll, change, or cancel health plan for NY subscribers

      Download
    • 2016 Enrollment/Change Form—VT Large Group

      Enroll, change, or cancel health plan for VT subscribers

      Download
    • 2016 Enrollment Instructions—NY Individual Download


  • Student Waiver Forms

    • Student Waiver Form: Out of Area Coverage - Medical Download
    • Student Waiver Form: Dental Download


Miscellaneous

  • Form 1095-B

    The Internal Revenue Service (IRS) recently issued new guidelines for the Form 1095-B, which shows the months during the previous year a member received coverage. MVP is no longer required to mail the form to members who have purchased their plan directly from MVP.

    Accessing Your Form 1095-B
    To view and download a copy now:

    To request a copy be mailed:

    • Fill out this form with your MVP member information, or
    • Call MVP’s Customer Care Center at 1-855-853-4877, Monday through Friday from 8:30 am to 5 pm.

    If you need help filling out your tax return or have questions about how to file your taxes using Form 1095-B, you should contact a tax professional, or you can call the IRS Tax Help Line at 1-800-829-1040 or visit the IRS website.


Pharmacy

  • Pharmacy Forms


Health Plans: Benefits at a Glance

  • 2017 NY Individual Off-Exchange Plans

    Download regional summaries of benefits and rates for Individual Off-Exchange (Premier) plans. Rates effective January 1, 2017 – December 31, 2017.

    • 2017 NY Premier Individual Plans—Albany (Off)

      NY Premier Plans at a glance for the Albany Region Off-Exchange

      Download
    • 2017 NY Premier Individual Plans—Buffalo (Off)

      NY Premier Plans at a glance for the Buffalo Region Off-Exchange

      Download
    • 2017 NY Premier Individual Plans—Mid-Hudson (Off)

      NY Premier Plans at a glance for the Mid-Hudson Region Off-Exchange

      Download
    • 2017 NY Premier Individual Plans—New York City (Off)

      NY Premier Plans at a glance for the New York City Region Off-Exchange

      Download
    • 2017 NY Premier Individual Plans—Rochester (Off)

      NY Premier Plans at a glance for the Rochester Region Off-Exchange

      Download
    • 2017 NY Premier Individual Plans—Syracuse (Off)

      NY Premier Plans at a glance for the Syracuse Region Off-Exchange

      Download
    • 2017 NY Premier Individual Plans—Utica/Watertown (Off)

      NY Premier Plans at a glance for the Utica/Watertown Region Off-Exchange

      Download


  • 2017 NY Individual On-Exchange Plans

    Download regional summaries of benefits and rates for Individual On-Exchange (Premier) plans. Rates effective January 1, 2017 – December 31, 2017.

    • 2017 NY Premier Individual Plans—Albany (On)

      NY Premier Plans at a glance for the Albany Region On-Exchange

      Download
    • 2017 NY Premier Individual Plans—Buffalo (On)

      NY Premier Plans at a glance for the Buffalo Region On-Exchange

      Download
    • 2017 NY Premier Individual Plans—Mid-Hudson (On)

      NY Premier Plans at a glance for the Mid-Hudson Region On-Exchange

      Download
    • 2017 NY Premier Individual Plans—New York City (On)

      NY Premier Plans at a glance for the New York City Region On-Exchange

      Download
    • 2017 NY Premier Individual Plans—Rochester (On)

      NY Premier Plans at a glance for the Rochester Region On-Exchange

      Download
    • 2017 NY Premier Individual Plans—Syracuse (On)

      NY Premier Plans at a glance for the Syracuse Region On-Exchange

      Download
    • 2017 NY Premier Individual Plans—Utica/Watertown (On)

      NY Premier Plans at a glance for the Utica/Watertown Region On-Exchange

      Download


  • 2017 VT Small Group and Individual Plans

    Download a summary of benefits and rates for Small Group and Individual plans. Rates effective January 1, 2017 – December 31, 2017.

    • 2017 Vermont Plans Product Placemat Download