Forms & Publications Library

Preferred Care members can view, download and print out a large selection of printed materials - forms, handbooks, current and past issues of Living Well member newsletters and more - right from this Web page. The information you need is just a click away!

Click on the Member Forms or Member Publications icons below to "jump" to the information you need!

                  

Member forms and publications are available in Portable Document File format (pdf). They are viewable with Adobe Acrobat Reader, a free application available by clicking
on this icon:

Authorization To Disclose Information (ADI)

Change Form - Gold and GoldAnywhere Plans

Claim Form - Dental for Gold Plan

Claim Form - Medical

COB Informational Form (Commercial)

COB Informational Form (Medicaid)

COBRA Coverage Form

Disenrollment Form - Gold Plans

Enrollment Application Gold and GoldAnywhere Plans (2008)

Enrollment / Change Form  Planes de Salud de Preferred Care Formulario de Solicitudde Inscripción/Cambios

Handicapped Dependent Application

Health Care Proxy

HealthDollars Reimbursement Request Form (Commercial)

WebMD® HealthDollar Rewards Reimbursement Form (for Preferred EPO and USdirect members)

HealthDollars Reimbursement Request Form (Gold)

Health Risk Assessment - for Option

Healthy NY Individual & Sole Proprietor Application & Instructions

Healthy NY Small Employers Application & Instructions

Medco by Mail Order Form - Commercial

Medco by Mail Order Form - for Gold / GoldAnywhere / USA Care Members

Medco Coordination of Benefits / Direct Claim Form (Commercial)

Medco Coordination of Benefits / Direct Claim Form (Gold/GoldAnywhere/USA Care)

Medco Vaccine and Administration (Injection) Claim Form (Gold/GoldAnywhere/USA Care)

Medicare Carve Out Election Form

Medicare Working Aged Survey

Out-Of-Area Waiver

PRA Plus Questionnaire (Medicare Heath Status Questionnaire)

Request for Coverage of Foster Dependent

Request for Restriction on the Use or Disclosure of Information

Student Certification Form

TEFRA/DEFRA

TriVantage Reimbursement Request Form