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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.

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.

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.

Please complete and sign this form to get reimbursed for eligible out-of-pocket expenses covered by your OTC, OTC Plus, or Flex card benefits.

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

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

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

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.

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

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

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.).

Please complete and sign this form and submit it within 60 days from the date of the Notice of Denial that you received.

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.

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.

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.

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.

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

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

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.

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

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

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

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.