Member Forms 

Common Forms for MVP Members

From enrollment forms to claims and reimbursement—and everything in between—access the forms you need for your plan type.

  • Individual and Family 
  • Medicare 
  • Medicaid
  • Child Health Plus (CHPlus)

Authorization Forms

Choose from the list below for disclosure forms and services requiring prior authorization:

Behavioral Health Forms

Find forms relating to behavioral health below: 

Claims and Reimbursement Forms

Medical and Dental Forms 

Choose from the list below for forms relating to medical and dental claims and reimbursements:

Spending Account Forms

Choose from the list below for forms relating to spending account claims: 

Well-Being Forms

Choose from the list below for forms relating to well-being benefits:

Other Forms

Find additional forms below:

Enrollment/Change Forms

Choose from the list below to enroll, make changes, or cancel a health plan subscriber:

Provider/Primary Care Provider Change Forms

Use the form below to change your primary care provider or for primary care providers to request reassignment of a patient: 

Special Enrollment Period Forms

Use the form below if you are seeking to enroll in an individual insurance plan outside of the annual Open Enrollment period:

Student Forms

Choose from the list below to waive or request extension of student coverages:

Transition of Care 

Use the form below if you’ve just joined MVP and you need to transition the care of yourself or a covered spouse or dependent from a non-MVP physician:

Miscellaneous Forms

Choose from the list below for other forms relating to individual and family plans:

Uncashed Checks

Please visit the Long Lost Money website to see if we have any uncashed checks in your name or in the name of your business. If so, please fill out the below form to claim your property: 

Advance Directives/Advance Care Planning–New York 

Choose from the list below for forms relating to advance directives, living wills, and health care proxies: 

Pharmacy Forms

Choose from the list below for forms relating to pharmacy benefits: 

Tax Forms

The IRS no longer requires taxpayers to provide the Form 1095-B with their taxes. You can still view or download a copy of your form now by signing into your online member account and selecting Tax Documents from the top-right menu. 

To request that we mail you a copy:

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 .

Visit the IRS website for forms relating to documentation of your health coverage: 

If you have a Medicare plan, view our Medicare Forms and Resources page.

Medicaid Managed Care Member Guide

 

Common Medicaid and HARP Forms

 

Harmonious Health Care Plan Member Guide

Member Guide (PDF)

Guía de los Afiliados (PDF)


Mental Health Parity and Addiction Equity Act 

MVP uses a team of clinical and compliance experts across the company to ensure continual compliance with the requirements of the Mental Health Parity and Addiction Equity Act (MHPAEA). MHPAEA is a federal law that prohibits insurance companies and managed care organizations from discriminating against individuals with mental health conditions (MH) or substance use disorders (SUD). MVP’s MHPAEA compliance program ensures that MVP uses financial requirements/quantitative treatment limits (FR/QTLs) and non-quantitative treatment limits (NQTLs) in a way that complies with parity. Parity requires each of these managed care practices to meet specific tests to assure that they are not being implemented in a discriminatory manner. MVP analyzes each FR/QTL/NQTL on an annual basis and updating the analysis as a part of any mid-year changes. Please contact MVP Member Services/Customer Care at the phone number listed on the back of your MVP Member ID card if you have any questions or concerns about MVP’s parity compliance. View guides to your Member ID card: 

 

Pharmacy 

Beginning April 1, 2023, all Medicaid members enrolled in MVP Medicaid Managed Care will receive their prescription drugs through NYRx, the Medicaid Pharmacy Program.

Information about the transition of the pharmacy benefit from MVP Medicaid Managed Care to NYRx, the Medicaid Pharmacy Program, can be found on health.ny.gov.

General information about NYRx, the Medicaid Pharmacy Program, can be found on health.ny.gov along with information for Members and Providers.

 

Advance Directives/Advance Care Planning–New York 

Choose from the list below for forms relating to advance directives, living wills, and health care proxies: 

New York State Department of Health Medicaid Rx Logo

Child Health Plus Member Guide

 

Common Child Health Plus (CHPlus) Forms

 

Pharmacy 

Choose from the list below for forms relating to pharmacy benefits: 

 

Advance Directives/Advance Care Planning–New York 

Choose from the list below for forms relating to advance directives, living wills, and health care proxies: 

 Reach Out to Us

We’re here with guidance and answers to your questions. 

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