Enrollment Forms, Applications, and Other Resources
Find forms for Large and Small Group, Individual, and Medicare plans, plus other common forms.
Broker Forms and Resources
- Authorization to Disclose Information
- Broker of Record for Individuals
- Broker of Record Letter
- MVP Spending Account Application
- Health Benefits Administrator and Plan Sponsor Designation
New York
Vermont
Group and Individual Plan Forms
See below for forms related to large group, small group, and individual plans.
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Large Group Plan Forms
- Employer Large Group Size Attestation
- Employer Large Group Size Attestation (Fillable)
- Grandfathered Plan Status Certification
- Grandfathered Plan Status Certification (Fillable)
- Independent Contractor Attestation
- Independent Contractor Attestation (Fillable)
- Large Group HMO Attestation
- Large Group HMO Attestation (Fillable)
New York Large Group
- Enrollment/Change Form – New York Large Group (Fillable)
- Enrollment/Change Form – New York Large Group (Fillable) – Spanish
- New York Large Group Billing and Contact Form
Vermont Large Group
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Small Group Plan Forms
- Affidavit of Group Sponsored Coverage for Common Law Employees
- Affidavit of Group Sponsored Coverage for Common Law Employees (Fillable)
- Attestation for Eligibility For Small Group Products
- Attestation for Eligibility For Small Group Products (Fillable)
- Grandfathered Plan Status Certification
- Grandfathered Plan Status Certification (Fillable)
- Independent Contractor Attestation
- Independent Contractor Attestation (Fillable)
New York Small Group
- Enrollment/Change Form – New York Small Group HMO (Fillable)
- Enrollment/Change Form – New York Small Group HMO (Fillable) – Spanish
- Enrollment/Change Form – New York Small Group EPO/PPO (Fillable)
- Enrollment/Change Form – New York Small Group EPO/PPO (Fillable) – Spanish
- New York Small Group Application HMO (Fillable)
- New York Small Group Application EPO/PPO (Fillable)
- New York Small Group Recertification Form
- New York Small Group Recertification Form (Fillable)
Healthy New York
- Enrollment/Change Form – Healthy New York
- Enrollment/Change Form – Healthy New York – Spanish
- Healthy New York Small Group Application
- Healthy New York Small Group Recertification Form
- Healthy New York Small Group Recertification Form (Fillable)
Vermont Small Group
- 2024 Vermont Small Group Plan Selection Form
- 2024 Vermont Small Group Plan Selection Form (Fillable)
- 2023 Vermont Small Group Plan Selection Form (Fillable)
- Enrollment/Change Form – Vermont Group Plan (Fillable)
- Vermont Small Group Application Form
- Vermont Small Group Application Form (Fillable)
- Vermont Small Group Recertification Form
- Vermont Small Group Recertification Form (Fillable)
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Individual Plan Forms
- 2024 Individual HSA Enrollment Packet
- 2023 Individual HSA Enrollment Packet
- One-Time Direct Payment Form (Fillable)
New York Individual
- Dental Enrollment/Change Form – Individual
- Enrollment/Change Form – New York Individual (Fillable)
- Enrollment/Change Form – New York Individual (Fillable) – Spanish
Vermont Individual
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Individual Medicare Plan Forms
See below for forms related to individual and employer group Medicare plans.
- Authorization to Disclose Information (ADI) Form
- Medicare Part D Comprehensive Formulary
- Medicare Advantage Certification Course
- Plan Recommendation Tool
- Scope of Sales Appointment Confirmation Form (Static)
Online Enrollment Tools
Plan Year 2024
Benefits at a Glance
- Capital District/Central/Southern Tier Region
- Hudson Valley Region
- Rochester/Buffalo Region
- UVM Health Advantage
Summary of Benefits
- Capital District/Central/Southern Tier Region Plans
- UVM Health Advantage
- Hudson Valley Region Plans
- MVP Medicare WellSelect with Part D (PPO) and MVP Medicare Patriot Plan with Part D (PPO)
- MVP Medicare Secure with Part D (HMO-POS), MVP Medicare Preferred Gold with Part D (HMO-POS), and MVP Medicare Preferred Gold without Part D (HMO-POS
- MVP Medicare Patriot Plan with Part D (PPO), MVP Medicare WellSelect Plus with Part D (PPO), and MVP Medicare Gold Giveback with Part D (PPO)
- Rochester/Buffalo Region Plans
- Other
Enrollment Applications
Plan Year 2023
Supplemental Benefit Information
Summary of Benefits
- Capital District/Central/Southern Tier Region Plans
- Vermont and Northern New York Region Plans
- Hudson Valley Region Plans
- Rochester/Buffalo Plans
- Other
Enrollment Applications
- Capital District/Central/Southern Tier Region
- Hudson Valley Region
- Rochester/Buffalo Region
- Vermont and Northern New York Region
- MVP DualAccess
- UVM Health Advantage
Medicare Star Ratings
- MVP Medicare Secure (HMO-POS), MVP Medicare Secure Plus (HMO-POS), MVP Preferred Gold with Part D (HMO-POS), MVP Preferred Gold without Part D (HMO-POS), and MVP DualAccess (HMO D-SNP)
- MVP WellSelect with Part D (PPO), MVP WellSelect Plus with Part D (PPO), MVP Medicare Patriot Plan (PPO), UVM Health Advantage Preferred, Secure, and Select with Part D (PPO)
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Employer Group Medicare Plan Forms
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