Medicare & Long-Term Care 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 Representatives Medical Records and Protected Health Information (PHI) OTC Benefits Enrollment Meal Delivery Pharmacy Benefits Coverage Determination

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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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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Use my OTC benefits

I want to use my OTC Plus benefit for healthy foods and utilities.*

You may be eligible if you have a qualifying chronic health condition. Please discuss with your provider and have them complete this form. For Life Improvement Plan (HMO D-SNP), Connection Plan (HMO D-SNP), and CompleteCare (HMO D-SNP) only.

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Enroll in a Healthfirst Medicare Advantage plan

I want to enroll in a Healthfirst Medicare Advantage plan.

Please complete and sign this form to enroll in a Healthfirst Medicare Advantage plan for the first time.

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I want to switch to a different Healthfirst Medicare Advantage plan.

If you have a Healthfirst Medicare Advantage plan and want to switch to a different one, please complete and sign this form.

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I want to enroll in a Managed Long-Term Care plan.

Please complete and sign this form with your provider. Then send the completed form to Healthfirst by fax or email:

Fax: 1-212-360-1121

Email: requests@healthfirst.org

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  • New York Independent Assessors Program Assessment Request Form

Request meal delivery after a hospital stay

I want to request home-delivered meals after a hospital stay.

If you want to request home-delivered meals after a stay of more than two days at an inpatient hospital or skilled nursing facility, please have your provider complete this form.

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  • Post-Discharge Meals Benefit Instructions and Request/Prescription Form

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.

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

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  • Pharmacy Claims Reimbursement Form

Ask Healthfirst to cover a prescription drug

I want Healthfirst to make a coverage determination (exception) on a prescription drug.

Please complete and sign this form if you want Healthfirst to make an exception for a prescription that is not covered by your plan, or if there are limits on the prescription’s use (e.g. coverage for a non-covered prescription, number of pills allowed, price, etc.).

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I want Healthfirst to reconsider their denial 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.

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Disclaimers

*Healthy foods and home utilities are special supplemental benefits for members enrolled in a Healthfirst dual-eligible special needs plan. To be eligible, you must have a chronic condition such as cardiovascular disorder, disabling mental health condition, diabetes, lung disorders, obesity, or another eligible condition not listed. Benefit eligibility is not based on your chronic condition alone.

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.

ATENCIÓN: Dispone de servicios de asistencia lingüística y otras ayudas, gratis. Llame al 1-866-305-0408 (TTY: 1-888-867-4132).

请注意：您可以免费获得语言协助服务和其他辅助服务。请致电 1-866-305-0408 (TTY: 1‑888‑542‑3821)。

Last update July 14, 2026 @ 2:44 pm

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