Essential Forms and Resources for Insurance Brokers
Access essential MVP Health Care broker forms and resources, including registration, authorization, plan applications, and Medicare documents for individual, small group, and large group plans.
Broker Registration Forms
Choose the form that best fits your role. Whether you're an individual broker or represent an agency, select the appropriate option below to get started.
Medicare
- Individual + Agency Broker Form
- New Agency Form
Commercial
If you’re looking to sell our commercial products, please email us at brokercustomerservice@mvphealthcare.com along with the following:
- Current Agency License — Required for agency appointment, if applicable.
- Current Individual Broker's License — Required for broker Appointment.
- Current E&O Certificate — MVP requires a minimum of $1,000,000 coverage.
- W9
- MVP will then review your documents and send you a request for any additional documentation needed.
Broker Forms and Resources
- Authorization to Disclose Information
- Broker of Record for Individuals
- Broker of Record Letter
- Health Benefits Administrator and Plan Sponsor Designation
Plan Selection Forms
Group and Individual Plan Forms
See below for forms related to large group, small group, and individual plans.
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- 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
- Enrollment/Change Form—New York Large Group—Spanish
- New York Large Group Billing and Contact Form
Vermont Large Group
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- 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
- Enrollment/Change Form—New York Small Group HMO —Spanish
- Enrollment/Change Form—New York Small Group EPO/PPO
- Enrollment/Change Form—New York Small Group EPO/PPO—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 NY - Spanish
- Healthy New York Small Group Application
- Healthy New York Small Group Application (Fillable)
- Healthy New York Small Group Recertification Form
- Healthy New York Small Group Recertification Form (Fillable)
Vermont Small Group
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See below for forms related to individual and employer group Medicare plans.
- Authorization to Disclose Information (ADI) Form
- Medicare Part D Comprehensive Formulary
- Plan Recommendation Tool
- Scope of Sales Appointment Confirmation Form
Online Enrollment Tools
Plan Year 2026
Benefits at a Glance
Summary of Benefits
- Capital District, Southern Tier, Hudson Valley, Central New York
- Hudson Valley
- Northern New York
- Rochester and Buffalo
Enrollment Applications
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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