2013 Member Forms for Medicare: Coordinated Benefits Plan (HMO)
We want to make signing up for the Medicare Coordinated Benefits Plan as easy as possible. Below, you will find all the forms and documents you need to make sure you get good health coverage.
Need help? Just call us or visit a Healthfirst community office near you. We can help you fill out any of these forms.
To open the forms, you will need Adobe Acrobat software installed on your computer. Download the software by clicking here. * Please note that clicking on this link will take you away from the Healthfirst website.
Benefits Documents |
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Coordinated Benefits Plan (HMO) |
Download the PDF | |
| Summary of Benefits |
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| Evidence of Coverage |
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General Forms and Documents |
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| Enrollment Form |
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| Short Enrollment Form |
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| Multi-language Interpreter Services | Multi-language |
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Appointment of Representative Form How to change or cancel your Healthfirst plan |
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| Health Care Proxy Information |
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Health Care Proxy Form How to make a living will and/or choose who will make health care |
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Member Reimbursement Form |
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Federal Privacy Notice |
English |
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New York State Privacy Notice |
English |
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Healthfirst Medicare Plan is a Coordinated Care plan with a Medicare contract and a contract with the New York Medicaid program.
H3359_MKT13_17 CMS Approved 11152012
