Frequently Used Forms

Frequently Used Forms

To help make your life easier, we give you quick access to a wide variety of frequently used forms, all in one convenient location.

General / Enrollment Forms

Affidavit of Surviving Spouse or Next of Kin
Allows the surviving spouse or next of kin to act on behalf of a deceased member.

Enrollment Application & Change Form
Complete an employer-sponsored enrollment. This form can be downloaded, printed, and submitted to your employer when enrolling in or changing your coverage or to elect COBRA coverage.

Explanation of Benefits (Sample)
This sample Explanation of Benefits (EOB) maps out each section of the form, providing you with helpful definitions and terms.

Formulary Exception Request Form
Use this form to request exceptions from the drug formulary, including drugs requiring prior authorization. Please note that your prescription drug rider and/or plan contract may exclude certain medications.

FSA/HRA General Claim Form – Independent Health
Use this form to submit an eligible FSA or HRA claim to Independent Health for reimbursement.

Health Care Proxy
Allows you to appoint someone you trust to make health care decisions for you if you lose the ability to make decisions yourself.

Medical/Pharmacy General Claim Form – Independent Health
Use to submit a claim to Independent Health for processing.

Member Complaint Form
Use to lodge a written complaint against Independent Health or to appeal an adverse determination. You may also fax this form to (716) 635-3504.

Other Insurance
If you or a family member has other health insurance, complete this form and send it to Independent Health, Attn: Coordination of Benefits, 511 Farber Lakes Drive, Buffalo, NY 14221.

State Government Plans

Formulary Exception Request Form
Medisource and Family Health Plus members can use this form to request exceptions from the drug formulary, including drugs requiring prior authorization. Please note that your prescription drug rider and/or plan contract may exclude certain medications.

NY Standard Gym Benefit Reimbursement Form
Complete this form to verify eligibility and get reimbursed up to $400 a year for membership in a qualifying gym.

Our New York state-sponsored programs
Include Child Health Plus, Family Health Plus, MediSource, Encompass I2, Encompass Plus I2 and Healthy New York Select. We provide more information on eligibility and enrollment for these programs on our State and Government Plans page.

Personal Care Service – Medicaid Order Form
Medicaid members who require Personal Care Services or Consumer Directed Personal Assistance Services will need to have their doctor complete this form. The form can be returned via fax to Independent Health at (716) 635-3820.

Personal Health Information Disclosure Forms

New York State Authorization to Disclose Confidential HIV Related Information Form
Use this form to authorize the disclosure of HIV/AIDS related personal health information [PHI] to designated individuals or groups of individuals. This authorization may include disclosure of information relating to alcohol and drug treatment, mental health treatment, and confidential HIV/AIDS related information.

Protected Health Information / HIPAA Authorization Form
Use this form to designate an individual or group of individuals with access to view and/or receive verbally your protected health information.

Choice Plus Plan

Choice Plus Facility Listing
View a complete list of participating facilities with the Choice Plus medical plan.

Choice Plus Physician Listing
View a current list of participating physicians within the Choice Plus plan.

Empower Plan

Empower Provider Confirmation Form
Use if you were advised to see your provider to discuss potential health issues.

FitWorks Rewards

FitWorks Rewards Paper Form
If you do not have a computer or internet access, you can keep track of the challenges you complete by completing and submitting this paper form.

Health Extras

Health Extras Card Request Form
Use this form to request a new Health Extras card if you are a member of a large group plan (Employer has > 100 employees) which includes this benefit.

If you are a member of a small group plan (Employer has < 100 employees) or you are a member of an Individual plan offered through the New York State of Health Marketplace which includes this benefit, log in or register to create an online member account and follow the online Health Extras registration process that automatically appears on-screen - guiding you though the Health Extras enrollment process and FitWorks® Well-Being Assessment to obtain your Health Extras card.

If you need to request a replacement Health Extras card, any member of a plan which includes the Health Extras benefit may use this form to request a replacement card.

Health Extras Participating Vendor Listing
Search health and wellness locations where you can use your Health Extras card.

Health Extras Reimbursement Form
Get reimbursed for eligible services when you weren't able to use your Health Extras card.

Max Plan

Wearable Wireless Activity Tracker Reimbursement Form
Use this form for your wearable wireless activity tracker reimbursement

55+ Dental Plan

2014 Enrollment Form
Enrollment application and instructions how to enroll in Independent Health’s 55+ Dental Plan

55+ Dental Plan – Option 1
Dental PPO plan highlights.

55+ Dental Plan – Option 2
Dental PPO plan highlights.