Forms & Resources
Note: All MVP forms and publications are PDF files.
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Claims & Reimbursement Forms
Wellness Rewards Screening Form
Medical Reimbursement Form
Routine Eye Glasses/Contact Lens Reimbursement Form
Post-Cataract Eyewear Reimbursement Form
Dental Claim Form
Hearing Aid Reimbursement Form
Flu Shot Reimbursement Form -
Pharmacy
CVS Caremark Mail Service Order Form
CVS Caremark Medicare Part D Prescription Claim Form
Coverage Determination Form
Request for Redetermination of Medicare Prescription Drug Denial
Drugs Older Adults Should Use with Caution* -
Enrollment Forms
Enrollment Form/Application
Medicare Part D - Pharmacy Coordination of Benefits (COB) Form
Disenrollment Rights & Responsibilities
Disenrollment Form
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Publications
Living Well Newsletter Spring 2018
Living Well Newsletter Winter 2017
Living Well Newsletter Fall 2017
Living Well Newsletter Summer 2017
Medicare Medical and Hospital Claims Monthly Report
2018 Membership Booklet: Get the Most from Your MVP Medicare Advantage Planantage Plan
Payment Center Help Guide -
Information Release/Authorization
Authorization to Disclose (ADI) Form
Actively Employed Information Form
Appointment of Representative Instructions
Appointment of Representative Form
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Advance Directives/Advance Care Planning
New York Advance Directives - What You Need to Know
NYSBA Living Will and Health Care Proxy Forms
New York State Department of Health
Organ and Tissue Donations
Medical Orders for Life Sustaining Treatment (MOLST) -
Miscellaneous
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Helpful Links
Medicare.gov (U.S. Government site for Medicare)
Medicare Ombudsman
Medicare Complaint Form
National Coverage Determinations from CMS
U.S. Social Security Administration
U.S. Department of Health and Human Services
New York State EPIC Program
New York State Office for the Aging
The Coalition for Medicare Choices
Last Updated October 2017