• Claims & Reimbursement Forms

  Medical and Dental Claim Reimbursement Form (PDF)
  Routine Eye Glasses/Contact Lens Reimbursement Form (PDF)
  Post-Cataract Eyewear Reimbursement Form (PDF)
  Medicare Noncovered List (PDF)

  
  

• Dental Coverage

  Learn more about dental coverage for Medicare members.

  
  

• Drug Coverage and Pharmacy

  CVS Caremark Mail Service Order Form (PDF)
  CVS Caremark Medicare Part D Prescription Claim Form (PDF)
  Coverage Determination Form
  Request for Redetermination of Medicare Prescription Drug Denial (PDF)

  
  

• Enrollment Forms

  2022 Individual Enrollment Application — Capital District, Southern Tier, Central New York (PDF)
  2022 Individual Enrollment Application — Hudson Valley Region (PDF)
  2022 Individual Enrollment Application — Rochester/Buffalo Region (PDF)
  2022 Individual Enrollment Application — Vermont Region (PDF)
  2022 Individual Enrollment Application — SmartFund MSA (PDF)
  2022 Individual Enrollment Application — Patriot Plan (PDF)
  2022 Individual Enrollment Application — MVP DualAccess (PDF)
  2022 Individual Enrollment Application — UVM Health Advantage (PDF)

  
  

• Disenrollment Forms

  Disenrollment Rights & Responsibilities (PDF)
  Disenrollment Form (PDF)

  
  

• How to Guides

  • Getting Care During a Disaster (PDF)
  • Payment Center Help Guide (PDF)

  
  

• Information Release/Authorization

  Authorization to Disclose Information (ADI) Form (PDF)
  Autorización para Revelar Información (Spanish) (PDF)
  Actively Employed Information Form (PDF)

  If you would like a friend, relative, doctor, or other person to act for you as your “representative” to ask for a coverage decision (such as whether a service is covered) or make an appeal, you may need to appoint them as your representative. If that person is already legally authorized to act as your representative under State law, you do not need to appoint them to represent you. If you want to appoint someone to be your representative, complete the “Appointment of Representative” form. The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give MVP a copy of the signed form. You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or to appeal a decision. Need more information on how to appoint a representative? Call the MVP Medicare Customer Care Center at 1-800-665-7924 (TTY: 1-800-662-1220). Representatives are available seven days a week, 8 am-8 pm, Eastern Time. From April 1-September 30, call Monday-Friday, 8 am-8 pm.

  
  

• Advance Directives/Advance Care Planning

  New York Advance Directives – What You Need to Know (PDF)

  NYSBA Living Will and Health Care Proxy Forms

  Vermont Department of Health Advance Directives

  
  

• Information on Grievances, Initial Determinations, Exceptions, and Appeals

  • Grievances and Appeals (PDF)

  
  

• Miscellaneous

  Unclaimed Property Claim Form (PDF)

  
  

Helpful Government and Medicare organization links

View Medicare’s official government site

Get help with Medicare complaints, grievances and information (Medicare Beneficiary Ombudsman)

Submit feedback about your plan via the Medicare Complaint Form

View the official Medicare Coverage Database (National Coverage Determinations)

Visit the official Social Security website

Visit the website for the U.S. Department of Health and Human Services

Get help paying for prescription drugs with New York’s Eldery Pharmaceutical Insurance Coverage (EPIC) program or Vermont Pharmaceutical Assistance (VPharm)

Find programs and services for the elderly at the New York State Office for the Aging

Help protect your Medicare rights