Your Source for Medicare Forms
There are many forms to keep track of as part of your Medicare Advantage coverage. We’ve gathered them here
for your convenience.
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Drug Coverage and Pharmacy
Find the forms you need regarding orders, claims and coverage determinations for Medicare Find the forms you need regarding orders, claims and coverage determinations for Medicare prescription drug coverage:
- CVS Caremark Mail Service Order Form (PDF)
- CVS Caremark Mail Service Order Form (PDF) — Spanish
- CVS Caremark Medicare Part D Prescription Claim Form (PDF)
- CVS Caremark Medicare Part D Prescription Claim Form (PDF) — Spanish
- Coverage Determination Form
- Request for Redetermination of Medicare Prescription Drug Denial (PDF)
2025 Plan Formularies
The following are formularies that are part of our 2025 Medicare Advantage Plans:
- 2025 Medicare Part D Comprehensive Formulary (PDF) (list of covered drugs)
- 2025 DualAccess Part D Comprehensive Formulary (PDF) (list of covered drugs)
2024 Plan Formularies
The following are formularies that are part of our 2024 Medicare Advantage Plans:
- 2024 Medicare Part D Comprehensive Formulary (PDF) (list of covered drugs)
- 2024 UVM Health Advantage Medicare Part D Comprehensive Formulary (PDF) (list of covered drugs)
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Advance Directives/Advance Care Planning
Find the forms you need regarding New York State and Vermont advance directives, as well as other advance care planning:
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Claims and Reimbursement Forms
Find the forms you need regarding filing claims and requesting reimbursements:
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Enrollment and Disenrollment Forms
Find the forms you need to enroll in one of our Medicare Advantage plans
2025 Enrollment Forms
- 2025 Individual Enrollment Application—Capital District, Southern Tier, Central New York (PDF)
- 2025 Individual Enrollment Application—Hudson Valley Region (PDF)
- 2025 Individual Enrollment Application—Rochester/Buffalo Region (PDF)
- 2025 Individual Enrollment Application—Northern New York Region (PDF)
- 2025 Individual Enrollment Application—MVP DualAccess (PDF)
- 2025 Individual Enrollment Application—UVM Health Advantage (PDF)
2024 Enrollment Forms
- 2024 Individual Enrollment Application—Capital District, Southern Tier, Central New York (PDF)
- 2024 Individual Enrollment Application—Hudson Valley Region (PDF)
- 2024 Individual Enrollment Application—Rochester/Buffalo Region (PDF)
- 2024 Individual Enrollment Application—Vermont Region (PDF)
- 2024 Individual Enrollment Application—MVP DualAccess (PDF)
- 2024 Individual Enrollment Application—UVM Health Advantage (PDF)
Below are the forms you need to disenroll from one of our plans:
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Government and Medicare Links
The following are resources outside the MVP website that can provide guidance on your Medicare questions:
- View Medicare’s official government site
- Get help with Medicare complaints, grievances and information (Medicare Beneficiary Ombudsman)
- Submit feedback about your plan via the Medicare Complaint Form
- View the official Medicare Coverage Database (National Coverage Determinations)
- Visit the official Social Security website
- Visit the website for the U.S. Department of Health and Human Services
- Get help paying for prescription drugs with New York’s Elderly Pharmaceutical Insurance Coverage (EPIC) program or Vermont Pharmaceutical Assistance (VPharm)
- Find programs and services for the elderly at the New York State Office for the Aging
- Help protect your Medicare rights
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Information Release/Authorization
Find the forms you need to allow us to release information to other people on your behalf:
- Authorization to Disclose Information (ADI) Form (PDF)
- Autorización para Revelar Información (Spanish) (PDF)
- Actively Employed Information Form (PDF)
“Appointment of Representative” Form (PDF) – If you would like a friend, relative, doctor, or other person to act for you as your “representative” to ask for a coverage decision (such as whether a service is covered) or make an appeal, you may need to appoint them as your representative. If that person is already legally authorized to act as your representative under State law, you do not need to appoint then to represent you.
If you want to appoint someone to be your representative, complete the “Appointment of Representative” form. The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give MVP a copy of the signed form.
You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or to appeal a decision.
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Miscellaneous
Find information you need related to special situations, such as filing a grievance or appeal of our policies, decisions, etc., or getting the care you need during disasters:
MVP Health Plan, Inc. is an HMO-POS/PPO/HMO D-SNP organization with a Medicare contract and a contract with the New York State Medicaid program. Enrollment in MVP Health Plan depends on contract renewal. MVP Health Plan, Inc. has been approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) until 12/31/2024 based on review of MVP Health Plan’s Model of Care. Health benefit plans are issued by MVP Health Plan, Inc., an operating subsidiary of MVP Health Care, Inc. Not all plans available in all states and counties. Every year, Medicare evaluates plans based on a 5-star rating system. Out-of-network/non-contracted providers are under no obligation to treat MVP Health Plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. For accommodations of persons with special needs at meetings, call 1-800-324-3899 (TTY 711).
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Last Updated: 10/1/2024
Speak to a Representative
To shop for a plan, contact an MVP Medicare Advisor at 1-800-324-3899 (TTY 711)
For questions about your plan, contact the MVP Medicare Customer Care Center at 1-800-665-7924 (TTY 711). If you have an MVP DualAccess plan, call 1-866-954-1872 (TTY 711).
From April 1-September 30, reach us Monday-Friday, 8 am-8 pm.
From October 1-March 31, reach us seven days a week, 8 am-8 pm.