Some forms are specific to the type of plan you have. Others are generic. See below for our most requested forms. Or click on your plan type further down the page to see more options.
If you have questions about which form to use, call the toll-free number on the back of your Healthfirst Member ID card.
Looking for a Plan Document? Click here to visit our Plan Documents page.
Authorization to Release Protected Health Information (PHI)
Complete this form to allow Healthfirst to share your health or coverage information with a family member, caregiver or other trusted person or organization. Only complete this form if you want to authorize Healthfirst to discuss your Protected Health Information (PHI) with someone other than you.
Appointment of Representative Form (AOR) for All Medicare Plans
Complete this form if you want to name someone you trust to act on your behalf to ask for an exception or appeal, or to make a complaint with Healthfirst.
*=Managed Long-Term Care Plans
General Forms
Authorization Forms to Share Medical Information
Complete this form to allow Healthfirst to share your Protected Health Information (PHI), including substance use information, with someone other than you.
Complete this form to allow Healthfirst to release records containing your Protected Health Information (PHI) with a family member, caregiver or other trusted person or organization.
Medicare Enrollment and General Benefit Forms
If you want to enroll in a Healthfirst Medicare Advantage plan for the first time, please complete and sign this form.
If you already have a Healthfirst Medicare Advantage plan and want to switch to another Healthfirst Medicare Advantage plan, please complete and sign this form.
If you would like to request home-delivered meals following a stay of more than two days at an in-patient hospital or skilled nursing facility, please have your provider complete this form.
Medicare Part D and OTC/Flex Forms
Complete and sign this form to request reimbursement for eligible out-of-pocket expenses covered by your OTC, OTC Plus or Flex card benefit.
If you would like Healthfirst to make an exception on a prescription (e.g. coverage for a non-covered prescription, number of pills allowed, price, etc.), or to request prescription reimbursement, please complete and sign this form.
If you would like to appeal a denied request for coverage of a prescription drug, please complete and sign this form and submit it within 60 days from the date of the Notice of Denial that you received.
If you want to request a new mail order prescription with CVS Caremark, or you want to refill a current prescription, please complete and sign this form.
If you paid out of pocket for prescription drugs and would like to submit a claim for reimbursement, please complete and sign this form.
Medicare Advantage Members:
Premiums, copays, coinsurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
Coverage is provided by Healthfirst Health Plan, Inc., Healthfirst PHSP, Inc., and/or Healthfirst Insurance Company, Inc. (together, “Healthfirst”). Healthfirst Medicare Plan has HMO and PPO plans with a Medicare contract. Our SNPs also have contracts with the NY State Medicaid program. Enrollment in Healthfirst Medicare Plan depends on contract renewal.
Healthfirst complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-305-0408 (TTY 1-888-867-4132).
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-866-305-0408 (TTY 1-888-542-3821).
Last update December 18, 2024 @ 3:21 pm
Y0147_MKT25_91 5128-24_M
General Forms
Authorization Forms to Share Medical Information
Complete this form to allow Healthfirst to share your Protected Health Information (PHI), including substance use information, with someone other than you.
Complete this form to allow Healthfirst to release records containing your Protected Health Information (PHI) with a family member, caregiver or other trusted person or organization.
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
Use this form to name someone to act on your behalf to assist with an authorization, complaint, grievance, or appeal. Email the completed form to: AORforms@healthfirst.org; or return it by mail to:
Appeals and Grievances Department, Healthfirst, P.O. Box 5166, New York, NY 10274-5166
General Forms
Authorization Forms to Share Medical Information
Complete this form to allow Healthfirst to share your Protected Health Information (PHI), including substance use information, with someone other than you.
Complete this form to allow Healthfirst to release records containing your Protected Health Information (PHI) with a family member, caregiver or other trusted person or organization.
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
Use this form to name someone to act on your behalf to assist with an authorization, complaint, grievance, or appeal. Email the completed form to: AORforms@healthfirst.org; or return it by mail to:
Appeals and Grievances Department, Healthfirst, P.O. Box 5166, New York, NY 10274-5166
General Member Forms
General Forms
Authorization Forms to Share Medical Information
Complete this form to allow Healthfirst to share your Protected Health Information (PHI), including substance use information, with someone other than you.
Complete this form to allow Healthfirst to release records containing your Protected Health Information (PHI) with a family member, caregiver or other trusted person or organization.
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
Use this form to name someone to act on your behalf to assist with an authorization, complaint, grievance, or appeal. Email the completed form to: AORforms@healthfirst.org; or return it by mail to:
Appeals and Grievances Department, Healthfirst, P.O. Box 5166, New York, NY 10274-5166
General Member Forms
*=Managed Long-Term Care Plans
General Forms
Authorization Forms to Share Medical Information
Complete this form to allow Healthfirst to share your Protected Health Information (PHI), including substance use information, with someone other than you.
Complete this form to allow Healthfirst to release records containing your Protected Health Information (PHI) with a family member, caregiver or other trusted person or organization.
Medicare Enrollment and General Benefit Forms
If you want to enroll in a Healthfirst Medicare Advantage plan for the first time, please complete and sign this form.
If you already have a Healthfirst Medicare Advantage plan and want to switch to another Healthfirst Medicare Advantage plan, please complete and sign this form.
If you would like to request home-delivered meals following a stay of more than two days at an in-patient hospital or skilled nursing facility, please have your provider complete this form.
Medicare Part D and OTC/Flex Forms
Complete and sign this form to request reimbursement for eligible out-of-pocket expenses covered by your OTC, OTC Plus or Flex card benefit.
If you would like Healthfirst to make an exception on a prescription (e.g. coverage for a non-covered prescription, number of pills allowed, price, etc.), or to request prescription reimbursement, please complete and sign this form.
If you would like to appeal a denied request for coverage of a prescription drug, please complete and sign this form and submit it within 60 days from the date of the Notice of Denial that you received.
If you want to request a new mail order prescription with CVS Caremark, or you want to refill a current prescription, please complete and sign this form.
If you paid out of pocket for prescription drugs and would like to submit a claim for reimbursement, please complete and sign this form.
Medicare Advantage Members:
Premiums, copays, coinsurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
Coverage is provided by Healthfirst Health Plan, Inc., Healthfirst PHSP, Inc., and/or Healthfirst Insurance Company, Inc. (together, “Healthfirst”). Healthfirst Medicare Plan has HMO and PPO plans with a Medicare contract. Our SNPs also have contracts with the NY State Medicaid program. Enrollment in Healthfirst Medicare Plan depends on contract renewal.
Healthfirst complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-305-0408 (TTY 1-888-867-4132).
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-866-305-0408 (TTY 1-888-542-3821).
Last update December 18, 2024 @ 3:21 pm
Y0147_MKT24_67 1102-23_M
General Forms
Authorization Forms to Share Medical Information
Complete this form to allow Healthfirst to share your Protected Health Information (PHI), including substance use information, with someone other than you.
Complete this form to allow Healthfirst to release records containing your Protected Health Information (PHI) with a family member, caregiver or other trusted person or organization.
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
Use this form to name someone to act on your behalf to assist with an authorization, complaint, grievance, or appeal. Email the completed form to: AORforms@healthfirst.org; or return it by mail to:
Appeals and Grievances Department, Healthfirst, P.O. Box 5166, New York, NY 10274-5166
General Forms
Authorization Forms to Share Medical Information
Complete this form to allow Healthfirst to share your Protected Health Information (PHI), including substance use information, with someone other than you.
Complete this form to allow Healthfirst to release records containing your Protected Health Information (PHI) with a family member, caregiver or other trusted person or organization.
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
Use this form to name someone to act on your behalf to assist with an authorization, complaint, grievance, or appeal. Email the completed form to: AORforms@healthfirst.org; or return it by mail to:
Appeals and Grievances Department, Healthfirst, P.O. Box 5166, New York, NY 10274-5166
General Member Forms
General Forms
Authorization Forms to Share Medical Information
Complete this form to allow Healthfirst to share your Protected Health Information (PHI), including substance use information, with someone other than you.
Complete this form to allow Healthfirst to release records containing your Protected Health Information (PHI) with a family member, caregiver or other trusted person or organization.
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
Use this form to name someone to act on your behalf to assist with an authorization, complaint, grievance, or appeal. Email the completed form to: AORforms@healthfirst.org; or return it by mail to:
Appeals and Grievances Department, Healthfirst, P.O. Box 5166, New York, NY 10274-5166
General Member Forms
General Forms
Authorization Forms to Share Medical Information
If you want to give someone (such as a family member, caregiver, or another company) access to your health or coverage information.
Complete this form to allow Healthfirst to release records containing your Protected Health Information (PHI) with a family member, caregiver or other trusted person or organization.
General Forms
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