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Forms & Applications:              
Please click on the following links, to open and print the forms you need.

COBRA Model Sample Letter for New York State


Excellus Healthy New York Employee Enrollment Form  

Excellus Healthy New York Employer ENROLLMENT PACKET - (New Groups)

Excellus EFT Automatic Payment Individual Plans

Excellus Blue Cross HIPAA Release Form

Excellus Blue Cross Subscriber Medical Claim Form

Excellus Blue Cross Waiver of Group Coverage


EPIC 2016 Program Highlights

Healthy NY:
Healthy NY Application for Small Business

Medicare Part-B Enrollment Form

Medicare Employer Statement

Scope of Appointment  

MVP Small Group Enrollment Form 

MVP Waiver of Coverage Form

ShelterPoint NYS Disability Benefits Application

ShelterPoint NYS Disability Claim Form

United Concordia Group Dental Application (for Employer)

United Concordia Employee Dental Enrollment Form

 Univera Healthy New York Employee Enrollment Form

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400 White Spruce Blvd. Suite C | Rochester, New York 14623
Local: (585) 224-8138 | Toll Free: (800) 458-7805 | Email:mking@aboutcentury.com
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