CDPHP Member Forms

Forms

Search or click on the name of the form you’re looking for.

Interested in paperless forms? Log in or create a member account to easily fill out and submit the below forms online.

Fitness Reimbursement Online
Release of Health Information Online
Medical and Vision Claims Online
Debit Card Substantiation - for FSA or HRA subscribers only
Request for a Debit Card - for FSA or HRA subscribers only
Flexible Spending Claims- for FSA subscribers only
Health Reimbursement Claims- for HRA subscribers only

Looking for paper forms? You can download, print, fill out, and mail in the forms below.

Completed forms can be mailed to: CDPHP, 500 Patroon Creek Blvd., Albany, NY 12206-1057

Accounting of Disclosures Request Form for Members
Autorizacion para la divulgacion de informacion medica
Claims Reimbursement Form - Dental, Vision & Medical
Coordination of Benefits
Delta Dental - Pediatric Dental Coverage Attestation Form for Members
Diabetes Prevention Program Reimbursement Form
Electronic Premium Deductions - Authorization Agreement
Electronic Premium Deductions - Cancellation Form
Electronic Reimbursement Form - Members
Embrace Claim Form
Employee Enrollment Application / Change Form
Fitness Reimbursement Form
Flexible Spending Account (FSA) Claim Form
Flexible Spending Account (FSA) Election Form
Handicap Waiver Request Form
Hixny Consent Form
Hixny Withdrawal of Consent Form
HRA Claim Form and Filing Instructions
HRA/ FSA Debit Card Request Form
Individual Enrollment Application Change Form
Inspection and Copying Request Form
Lasik Reimbursement Member Claim Form
Maternal Reimbursement Form
Medical Exception Request Form
Medicare Advantage Disenrollment Form - Individual
Medicare Caremark Part D Mail Order Form
Medicare Coordination of Benefit
Medicare HMO Enrollment Form
Medicare HMO Plan Change Election Form
Medicare Medical Exception - Prior Authorization Form
Medicare Member Appeal Form
Medicare Member Complaint Form
Medicare PPO Enrollment Form
Medicare PPO Plan Change Election Form
Member Appeal Form
Member Claim Form
Member Complaint Form
Part D Prescription Claim Form
Prescription Reimbursement – Standard Claim Form
Protected Member Address Form
Request for Amendment of Health Information Form
Release of Health Information Authorization Form
Vision Hardware Reimbursement Form
Weight Management Reimbursement Form

Resources

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Search or click on the name of the form you’re looking for.

Interested in paperless forms? Log in or create a member account to easily fill out and submit the below forms online.

Looking for paper forms? You can download, print, fill out, and mail in the forms below.