Find a Form

Find commonly used forms to help you manage your coverage.

Some forms are specific to your benefit plan. Other forms apply across plans. If you have questions about which forms are meant for your use, call the toll-free number on the back of your Healthfirst Member ID card. Can’t find your Member ID card?

Give permission to share information

I want to give someone permission to talk to Healthfirst about my health or insurance coverage.

Complete this form to allow Healthfirst to share your health or coverage information with a family member, caregiver, or other trusted person or organization. Only complete this form if you want to authorize Healthfirst to discuss your Protected Health Information (PHI) with someone other than you.

For All Plans

I want Healthfirst to share my medical records with a person or an organization I trust.

Complete this form to allow Healthfirst to release records containing your Protected Health Information (PHI) with a family member, caregiver, or other trusted person or organization.

For All Plans

Allow someone to act on your behalf

I want to give someone permission to ask Healthfirst for an exception or make an appeal or complaint on my behalf.

Complete this form if you want to name someone you trust to act on your behalf to ask for an exception or appeal, or to make a complaint with Healthfirst.

For Medicare Plans

  • Appointment of Representative Form (AOR)
I want to give someone permission to talk to Healthfirst about an authorization, complaint, grievance, or appeal.

Use this form to name someone to act on your behalf to assist with an authorization, complaint, grievance, or appeal. Email the completed form to: AORforms@healthfirst.org; or return it by mail to:
 Appeals and Grievances Department, Healthfirst, P.O. Box 5166, New York, NY 10274-5166

For Non-Medicare Plans

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Links to non-Healthfirst websites are provided for your convenience only. Healthfirst is not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites.

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