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 |
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Child Health Plus |
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About Your Child Health Plus Program (Subscriber Contract) |
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| Benefit Grid |
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| Prescription Drugs Covered By Your Program (Formulary) |
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| Enrollment Application | English Español |
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| Child Health Plus Renewal Application | English Español |
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General Forms and Documents |
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| Download the PDF | ||
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Member Complaint Form |
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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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Physician Nomination Form Ask Healthfirst to add a doctor to the network |
English Español |
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Transportation Reimbursement Form How to get money back for car service to or from your child’s doctor visits |
English |
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Member Status Change Form How to change or cancel your Healthfirst plan or program |
English |
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Prescription Home Delivery Form How to ask for home delivery of your child’s prescription medications |
English |
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Income Review Form Ask Healthfirst to change your premium (monthly payment) due to a change in your income or household size |
English |
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Quest Diagnostic Preferred Provider List Testing labs covered by Child Health Plus |
English |
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NY State Quality Assurance Reporting Requirements* (QARR) |
English | |
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New York State Privacy Notice |
English |
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* = By clicking this link, you will be sent to another website.
