Member Forms

Member Forms

Paperwork Made Easy

For your convenience, all the forms you need to participate in the CDPHP network can easily be downloaded to your computer.

If you have any questions or need additional assistance, please contact CDPHP Member Services.

• General Forms
• Appeal Form for Members
  This form may be used to file an appeal regarding any adverse decision made by CDPHP.
• Authorization to Release Health Information
  Use this form to authorize CDPHP to disclose your protected health information.
• Autorizacion para la divulgacion de informacion medica
  Use esta forma para dar autorizacion a CDPHP de divulgar informacion de su seguro medico, la cual esta bajo proteccion.
• Authorization for Release of Confidential HIV Related Information
  Complete if you wish to authorize disclosure of HIV/AIDS-specific records.
• Complaint Form for Members
  Use to file a formal complaint regarding the care or service which you have received from CDPHP or any of our participating providers.
• Electronic Premium Deductions - Authorization Agreement
  This option is available ONLY for Non Group, Medicare Choice, and Healthy New York subscribers.
• Electronic Premium Deductions - Cancellation Form
  Complete and return this form if you wish to cancel automatic premium withdrawals.
• Handicap Waiver Request
  For a subscriber's unmarried child age 19 or older to be enrolled as a dependent. Use to provide evidence of the dependent's handicapping conditions.
• Health Care Proxy
  The New York Health Care Proxy Law allows you to appoint someone you trust to make health care decisions for you in the event you lose the ability to make decisions yourself.
• Medical Insurance Information Release Affidavit
  The Medical Insurance Information Release Affidavit must be completed and returned to CDPHP, along with a copy of the deceased member’s death certificate, in order for CDPHP to release his or her medical insurance information. By completing this affidavit, you will attest that [Member’s Name] died without a legal will; that you have elected not to settle the estate; and that you have not applied, nor do you intend to apply, to the appropriate court for appointment as the administrator of the estate.
• Medicare Appointment of Representative
  CDPHP Medicare plan members may appoint any individual (e.g., a friend, relative, lawyer) as your representative to assist with you with understanding and following coverage determinations, exceptions, appeals or grievances.
• Pre-Existing Condition Questionnaire - CDPHP UBI
  This form must be completed for each CDPHP UBI member if your contract has a pre-existing condition clause. Completing this form will ensure claims are adjudicated in a timely manner and according to your contract.
• Pre-Existing Condition Questionnaire - Healthy New York
  This form must be completed for each Healthy New York member if your contract has a pre-existing condition clause. Completing this form will ensure claims are adjudicated in a timely manner and according to your contract.
• Pre-Existing Condition Questionnaire - Non-Group
  This form must be completed for each Non-group member if your contract has a pre-existing condition clause. Completing this form will ensure claims are adjudicated in a timely manner and according to your contract.
• Student Verification Information
  Use to certify that a dependent remains eligible for coverage under a Full Time Student Rider.

• Enrollment Applications & Information
• Child Health Plus Enrollment
  There are two different ways to apply for Child Health Plus. To determine which application you should use, please visit the Child Health Plus Web site.
• Family Health Plus Enrollment
  To apply for Family Health Plus, you will need to have a personal interview where you will complete an application, provide proof of certain information, and select a health plan. Please visit the Family Health Plus Web site for more information.
• Healthy New York Enrollment - Individuals and Sole Proprietors
  Download the standard Healthy New York Individual application and return completed form to CDPHP.
• Healthy New York Recertification - Individuals and Sole Proprietors
  Download the standard Healthy New York Individual recertification form and return the completed form to CDPHP by the recertification deadline.
• Healthy New York Enrollment - Small Businesses
  Download the standard Healthy New York Small Business application and return completed form to CDPHP.
• Medicare Enrollment - Individuals
  Enroll online or download an enrollment application for your chosen CDPHP Medicare plan.
• Non-Group Enrollment Application and Change Form
  Non-group HMO & POS member application and change form. For new enrollment and enrollment changes.
• Select Plan (Managed Medicaid)
  Enrollment in Select Plan, a Medicaid managed care program, is available through your local department of social services.

• Prescription Forms & Lists
• CDPHP Preferred Drug List
  The CDPHP Preferred Drug List is a guide to preferred generic and brand medications that are clinically appropriate and cost-effective.
• CDPHP Three-tier Drug List
  View a chart that shows the tier status of the most commonly used pharmaceuticals.
• CDPHP Clinical Formulary
  The CDPHP Clinical Formulary is a useful reference and informational tool to assist practitioners in selecting clinically appropriate and cost-effective drug therapies.
• Excluded Drug List for Closed Formulary
  The CDPHP Excluded Drug List represents an alphabetical listing of drugs that are currently excluded (not covered) on the CDPHP closed formulary.
• Medical Exception Request
  Applies to closed formulary only. CDPHP members with a prescription benefit can request to initiate a medical exception review for drugs that are excluded (not covered) on the closed formulary.
• Medicare Drug Plans Formulary - 2008
  List of covered drugs for CDPHP Medicare plans that offer Part D prescription drug coverage. Also see Notice of Formulary Updates.
• Medicare Notice of Formulary Updates
  List of updates and changes to the 2008 CDPHP Medicare Drug Plans Formulary.
• Prescription Claim Form - Standard Claim
  Complete when requesting reimbursement for covered prescription drugs.
• Prescription Claim Form - Foreign Claim
  This form is to provide direct reimbursement for covered prescriptions that were purchased outside the United States.
• Prescription Claim Form - Medicare with Part D
  This form is to provide direct reimbursement for covered prescription drugs purchased by members of Medicare with Part D.
• Prescriptions By Mail - Order Form
  By ordering your maintenance drugs through the mail, you can obtain up to a three (3)-month supply of drugs at a discounted rate, depending on your drug rider.
• Prescriptions By Mail - Overview Brochure
  Members with prescription drug coverage can save money by using the Prescriptions By Mail Service to have maintenance medications delivered directly to your home or office.
• Prescriptions By Mail - Overview Brochure for Medicare Part D
  Medicare Plan Members with Part D prescription drug coverage can save money with the Prescription By Mail Service option.
• Quantity Limits for Select Drugs
  CDPHP, working closely with the P&T Committee members, has chosen to limit the quantity of certain drugs that a pharmacy may dispense to a member.

• HIPAA Member Rights Forms
• Accounting of Disclosures Request Form
  This form enables you to request a listing of disclosures made by CDPHP for purposes other than treatment, payment, or health care operations.
• Confidential Communications Request Form
  CDPHP members have the right to receive communications by alternative means or at alternative locations. Complete this form if you would like to receive communications from CDPHP at a different address.
• Inspection and Copying Request Form
  Complete if you would like to inspect or copy your protected health information.
• Request for Amendment of Health Information
  File this form to request that your protected health information be corrected.

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