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 |
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Medicaid Managed Care |
Download the PDF | |
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About Your Medicaid Managed Care Program (Member Handbook) |
English Español 中文 (Coming Soon) |
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| Benefit Grid |
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| Your Benefits Now And In The Future | English |
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| Prescription Drugs Covered By Your Program (Formulary) | English |
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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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HIPAA Authorization for Disclosure of
To authorize Healthfirst to disclose protected health information to a third party specified by the member. |
English |
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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.
