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Healthfirst
100 Church Street
New York, NY 10007

Have any questions?

Healthfirst
100 Church Street
New York, NY 10007 - See more at: http://www.healthfirstny.org/get-health-insurance.html#sthash.Is3rFtPx.dpuf

Medicaid, Child Health Plus, and Family Health Plus
1-866-463-6743
TDD/TTY English 1-888-542-3821
TDD/TTY Español 1-888-867-4132
Monday - Friday, 8 am to 6 pm

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Child Health Plus - Materials and Forms

We want to make signing up for the Child Health Plus program as easy as possible. Below, you will find all the forms and documents you need to make sure your child gets 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.


Benefits Documents

Child Health Plus

Download the PDF

About Your Child Health Plus Program (Subscriber Contract)

English

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Benefit Grid

English

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Prescription Drugs Covered By Your Program (Formulary)

English


General Forms and Documents

  Download the PDF

Member Complaint Form

English

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Health Care Proxy Information 

English

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Health Care Proxy Form

How to make a living will and/or choose who will make health care
decisions for you*   

English

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Physician Nomination Form

Ask Healthfirst to add a doctor to the network

English    Español PDF icon image

Transportation Reimbursement Form

How to get money back for car service to or from your child’s doctor visits

English   PDF icon image

Member Status Change Form

How to change or cancel your Healthfirst plan or program

English PDF icon image

Prescription Home Delivery Form

How to ask for home delivery of your child’s prescription medications

English PDF icon image

Income Review Form              

Ask Healthfirst to change your premium (monthly payment) due to a change in your income or household size

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Quest Diagnostic Preferred Provider List

Testing labs covered by Child Health Plus

English PDF icon image

NY State Quality Assurance Reporting Requirements* (QARR)

English  

New York State Privacy Notice

English PDF icon image

* = By clicking this link, you will be sent to another website.

Last update 2014-09-05 10:14