Forms & Documents

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.

Commonly Used Forms:

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.

Download the PHI Release Form

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.

Download the AOR Form

Viewing documents for:

Medicare & Managed Long Term Care Plans

* = managed long-term care plan

General Forms

Helpful Member and Plan Information
Authorization Forms to Share Medical Information
Medicare Enrollment and General Benefit Forms
65 Plus Plan (HMO)
CompleteCare (HMO D-SNP)*
Connection Plan (HMO D-SNP)
Increased Benefits Plan (HMO)
Life Improvement Plan (HMO D-SNP)
Senior Health Partners*
Signature (HMO)
Signature (PPO)
Medicare Part D and OTC/Flex Forms

Plan Documents

Helpful Member and Plan Information
Authorization Forms to Share Medical Information
Medicare Enrollment and General Benefit Forms
65 Plus Plan (HMO)
CompleteCare (HMO D-SNP)*
Connection Plan (HMO D-SNP)
Increased Benefits Plan (HMO)
Life Improvement Plan (HMO D-SNP)
Senior Health Partners*
Signature (HMO)
Signature (PPO)
Medicare Part D and OTC/Flex Forms

Additional Resources

Helpful Member and Plan Information
Authorization Forms to Share Medical Information
Medicare Enrollment and General Benefit Forms
65 Plus Plan (HMO)
CompleteCare (HMO D-SNP)*
Connection Plan (HMO D-SNP)
Increased Benefits Plan (HMO)
Life Improvement Plan (HMO D-SNP)
Senior Health Partners*
Signature (HMO)
Signature (PPO)
Medicare Part D and OTC/Flex Forms

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”). Plans contain exclusions and limitations.

Healthfirst Health Plan, Inc. offers HMO plans that contract with the Federal Government. Healthfirst Medicare Plan has a contract with New York State Medicaid for Healthfirst CompleteCare (HMO SNP) and a Coordination of Benefits Agreement with the New York State Department of Health for the Healthfirst Life Improvement Plan (HMO SNP). Enrollment in Healthfirst Medicare Plan depends on contract renewal.

Healthfirst Medicare Plan, Inc. 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 January 25, 2024 @ 1:57 pm

Y0147_MKT24_67 1102-23_M

Medicaid Plans

General Forms

Essential Plan
Helpful Member and Plan Information
Authorization Forms to Share Medical Information
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
General Member Forms
Medicaid Managed Care
Personal Wellness Plan
Child Health Plus
Platinum
Gold
Silver
Bronze
Green

Plan Documents

Essential Plan
Helpful Member and Plan Information
Authorization Forms to Share Medical Information
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
General Member Forms
Medicaid Managed Care
Medicaid Prescription Drug and OTC Formulary
Personal Wellness Plan
Medicaid Prescription Drug and OTC Formulary
Child Health Plus
Platinum
Gold
Silver
Bronze
Green

Additional Resources

Essential Plan
Helpful Member and Plan Information
Authorization Forms to Share Medical Information
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
General Member Forms
Medicaid Managed Care
Personal Wellness Plan
Child Health Plus
Platinum
Gold
Silver
Bronze
Green

Essential Plans

General Forms

Essential Plan
Helpful Member and Plan Information
Authorization Forms to Share Medical Information
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
General Member Forms
Medicaid Managed Care
Personal Wellness Plan
Child Health Plus
Platinum
Gold
Silver
Bronze
Green

Plan Documents

Essential Plan
Helpful Member and Plan Information
Authorization Forms to Share Medical Information
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
General Member Forms
Medicaid Managed Care
Personal Wellness Plan
Child Health Plus
Platinum
Gold
Silver
Bronze
Green

Additional Resources

Essential Plan
Helpful Member and Plan Information
Authorization Forms to Share Medical Information
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
General Member Forms
Medicaid Managed Care
Personal Wellness Plan
Child Health Plus
Platinum
Gold
Silver
Bronze
Green

Leaf and Leaf Premier Plans

General Forms

Essential Plan
Helpful Member and Plan Information
Authorization Forms to Share Medical Information
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
General Member Forms
Medicaid Managed Care
Personal Wellness Plan
Child Health Plus
Platinum
Gold
Silver
Bronze
Green

Plan Documents

Essential Plan
Helpful Member and Plan Information
Authorization Forms to Share Medical Information
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
General Member Forms
Medicaid Managed Care
Personal Wellness Plan
Child Health Plus
Platinum
Gold
Silver
Bronze
Green

Additional Resources

Essential Plan
Helpful Member and Plan Information
Authorization Forms to Share Medical Information
Designate a Representative to Assist with Authorizations, Complaints, Grievances, and Appeals
General Member Forms
Medicaid Managed Care
Personal Wellness Plan
Child Health Plus
Platinum
Gold
Silver
Bronze
Green

Pro and Pro Plus Plans

General Forms

Authorization Forms to Share Medical Information
General Member Forms
Platinum
Gold
Silver
Bronze

Plan Documents

Authorization Forms to Share Medical Information
General Member Forms
Platinum
Gold
Silver
Bronze

Pro and Pro Plus Plans

General Forms

Authorization Forms to Share Medical Information
General Member Forms
Platinum
Gold
Silver
Bronze

Plan Documents

Authorization Forms to Share Medical Information
General Member Forms
Platinum
Gold
Silver
Bronze