Individual & Family Plans Member Forms

If you're not sure which form you need, please call the Member Services phone number on your Healthfirst Member ID card.

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Appointment of Representative Medical Records and Protected Health Information (PHI) Reimbursement Pharmacy Complaints Member Status Change

Allow someone to act on my behalf

I want to give someone permission to ask Healthfirst for an exception or make an appeal or complaint on my behalf.

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.

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I want to give someone permission to talk to Healthfirst about an authorization, complaint, grievance, or appeal.

Please use this form to give someone permission to help with an authorization, file a complaint or grievance, or make an 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

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  • Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals

Share my medical records or protected health information (PHI)

I want to let someone talk to Healthfirst about my health or coverage.

If you want to give a family member, caregiver, or trusted organization permission to talk to Healthfirst about your Protected Health Information (PHI) or insurance coverage, please complete and sign this form.

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I want Healthfirst to share copies of my medical records with someone.

If you want Healthfirst to release records that contain your Protected Health Information (PHI) to a family member, caregiver, or trusted health organization, please complete and sign this form.

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Get reimbursed for out-of-pocket purchases

I want to get reimbursed for prescription drugs I paid for out of pocket.

Please complete and sign this form to submit a claim to get reimbursed.

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  • Pharmacy Claims Reimbursement Form

I want to submit my gym visits to ExerciseRewardsTM.

Please complete and submit this form if you attend a qualifying fitness center that doesn't submit visits on your behalf.

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I want to get reimbursed for healthcare services I paid for out of pocket.

Please complete and submit this form with supporting documentation (receipts and bills) to get reimbursed for eligible services that were paid for out of pocket.

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Use my pharmacy benefits

I want to request a mail-order prescription.

Please complete and sign this form to request a new mail-order prescription or to refill a current mail-order prescription.

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I want to get reimbursed for prescription drugs I paid for out of pocket.

Please complete and sign this form to submit a claim to get reimbursed.

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  • Pharmacy Claims Reimbursement Form

Report a problem or make a complaint

I want to tell Healthfirst about a problem with my care.

If you’re unsatisfied with your Healthfirst experience, a provider, or a health service, please use this form.

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Report a change or get a new Member ID card

I want to tell Healthfirst about a life change, request a Primary Care Provider (PCP) change, or request a new Member ID card.

Use this form to update your contact information, report a change in your family size, or request a PCP change or new Member ID card.

If you enrolled through NY State of Health (NYSOH) and need to report a life change, do not complete this form. You must report these changes to NYSOH directly at nystateofhealth.ny.gov

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