Employer Forms

Employer Forms

Paperwork Made Easy

For your convenience, all the forms you need for your group can easily be downloaded to your computer.

If you have any questions or need additional assistance, please contact CDPHP Employer Services at 1-866-258-1785.

• Employer Group Applications
• Employer Application Form - CDPHP, CDPHP UBI, and FoxFirst
• Employer Group Application - ASO
• Employer Group Application - Dental
• Employer Group Application - Group Medicare
• Employer Group Application - Healthy New York
• Employer Group Application Supplement - Healthy New York

• Employee (Member) Applications & Change Forms
• Employee Application/Change Form - CDPHP, CDPHP UBI, and FoxFirst
• Employee Application / Change Form - ASO
• Employee Application / Change Form - Dental
• Employee Application / Change Form - Healthy New York
• Employee & Retiree Application / Change Form - Group Medicare

• Employer Online Access
• Employer Secure Access Request

• General Forms
• Authorization to Release Health Information
• Handicap Waiver Request
• Medicare Group - 30-Day Notice of Change Sample Letter
• Medicare Group - Census Roster of Medicare Eligible Employees and Retirees
• Medicare Group - Checklist for Submitting a Medicare Choices Group Plan Application
• Complete Medicare Group - Attestations and Guidance
• Pre-Existing Condition Questionnaire - CDPHP UBI
• Prescription Reimbursement - Foreign Claim Form
• Prescription Reimbursement - Standard Claim Form
• Prior Authorization Requirements - CDPHP UBI
• Student Verification Form

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