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Have any questions?

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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New Member Forms for Medicaid Managed Care

We want to make signing up for the Medicaid Managed Care program 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

Medicaid Managed Care

Download the PDF

About Your Medicaid Managed Care Program (Member Handbook)

English  Español  中文  

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Benefit Grid

English

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Your Benefits Now And In The Future English PDF icon image
Prescription Drugs Covered By Your Program (Formulary) English PDF icon image

 


General Forms and Documents

  Download the PDF

Member Complaint Form

English

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Medicaid Paper Claims Form English PDF icon image

HIPAA Authorization for Disclosure of
Health Information Form

 

To authorize Healthfirst to disclose protected health information to a third party specified by the member.

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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

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Prescription Home Delivery Form

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

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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

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Quest Diagnostic Preferred Provider List

Testing labs covered by Child Health Plus

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NY State Quality Assurance Reporting Requirements* (QARR)

English  

New York State Privacy Notice  

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

Last update 2014-04-04 09:15