Forms & Applications:

Please click on the following links, to open and print the forms you need.

 

PAID FAMILY LEAVE APPLICATIONS

(Click on form needed, will take you to website of correct forms)

SCROLL DOWN TO BOTTOM OF WEBSITE FOR THE SPECIFIC PAID FAMILY LEAVE FORMS:

Bond with a Newborn, a Newly Adopted or Fostered Child

Care for a Family Member with Serious Health Condition

Assist Families in Connection with a Military Deployment

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 Prescription Drug Claim Form 2020.pdfg Form

Excellus Blue Cross Waiver of Group Coverage

EPIC APPLICATION Form

EPIC 2020 Program Highlights


Healthy NY:
  
Healthy NY Application for Small Business



Medicare Part - B Enrollment Form

Medicare Employer Statement

Scope of Appointment  
  

MVP:
MVP Small Group Enrollment Form 

MVP Waiver of Coverage Form



ShelterPoint NYS Disability Benefits Application

ShelterPoint NYS Disability Claim Form

Paid Family Leave for yourself due to COVID - 19 quarantine/Isolation

Request for COVID-19 Quarantine PFL – Child




United Concordia Group Dental Application (for Employer)

United Concordia Employee Dental Enrollment Form




 Univera Healthy New YorkEmployee Enrollment Form