Authorization to Disclose Information (ADI)
Members have the right to authorize representatives to receive personally identifiable information by completing this form.
Change Form - Gold and GoldAnywhere Plans
If you are changing plans you should use this form. This form may not be used to enroll for the first time. (To enroll for the first time, please use the "Gold and GoldAnyhwere Plan Enrollment Application" below.)
Claim Form - Dental for Gold Plan
While most dentists will file dental claims electronically, you can print this form to take a paper copy to your next dentist visit.
For subscribers who submit claims to Preferred Care for payment, this claim form is used to submit all bills. A separate claim form must be completed for each covered person's bills, and a separate claim form must accompany each bill.
COB Informational Form (Commercial)
Using this form, members inform Preferred Care of other types of health care insurance that they have.
COB Informational Form (Medicaid)
Using this form, members inform Preferred Care of other types of health care insurance that they have.
Group Health Insurance Continuation Coverage Form (COBRA)
Disenrollment Form - Gold Plans
Please read this form carefully for instructions on disenrolling from the Preferred Care Gold or GoldAnywhere plan.
Enrollment Application - Gold and GoldAnywhere Plans
Use this form to become a Preferred Care Gold or GoldAnywhere plan member. This form may not be used to change plans.
Form to complete to enroll or change existing enrollment for Preferred Care Commercial health care plans for members who are not Medicare eligible (i.e. under 65 and not disabled). Individuals who would like to enroll in Preferred Care or update their existing enrollment with Preferred Care through their employer group should complete this form and then forward it to their Human Resource department for approval.
Handicapped Dependent Application
Form to complete to request review of disabled status for dependent children over 19 who the subscriber (contract holder) would like to begin or continue to have covered as a dependent on their contract. The dependent must meet all other eligibility requirements. Both the subscriber and the dependent's physician must complete their respective sections of the form, then forward the completed form to Preferred Care.
A document that appoints a person to make medical decisions in case of incapacitation. It may also contain specific instructions of the members wishes under certain medical conditions.
HealthDollars Reimbursement Form
Subscribers should use this form to be reimbursed for up to $50 in HealthDollarssm
Health Risk Assessment for Option Plan Members
Upon enrollment, each Option member is required to complete a health risk assessment survey as a part of our contract to provide Medicaid services with the State. The survey is sent to identify high- risk members and those in need of immediate medical attention (case management).
Healthy NY Individual & Sole Proprietor Application & Instructions
Link to application form and instructions for individual enrollment in Healthy New York health plan.
Healthy NY Small Employers Application & Instructions
Link to instructions and the application for employer or group enrollment in Healthy New York plan
Medco Order Form - For Preferred Care Gold / GoldAnywhere / USA Care Members
Submission form for new prescriptions received by members from their doctors. Required for all new prescriptions.
Medco Coordination of Benefits / Direct Claim Form for Gold / GoldAnywhere / USA Care Members
Use this form to submit claims to Medco. You must complete a separate claim form for each pharmacy used and for each patient.
Medco Vaccine Form - Gold / GoldAnywhere / USA Care Members
This claim form is for reimbursement of covered Part D vaccines
and their administration (injection). Please consult your
Evidence of Coverage for specific coverage information.
Medicare Carve Out Election Form
This form is to be completed if 1) you wish to remain with your current benefits, 2) understand that Medicare is still the beneficiary's primary coverage, and 3) understand that full benefits are not payable due to Medicare eligibility regardless of actual Medicare status.
The Center for Medicare and Medicaid Service, a Federal agency under the Social Security Administration, requires this annual survey to determine if a Medicare recipient or spouse is working or has medical coverage under another plan.
Form to be completed by members who reside outside of the Preferred Care nine county area but continue to qualify for coverage. Waiver confirms that member understands they will only be eligible for emergency treatment unless their coverage is done by providers within the Preferred Care coverage area. Form must be completed by the subscriber then forwarded to Preferred Care.
PRA Plus Questionnaire (Medicare Heath Status Questionnaire)
This questionnaire surveys the health statue of Medicare recipients. It is required by the Center for Medicare and Medicaid Services. The survey is sent to identify high- risk members and those in need of immediate medical attention (case management).
Request for Coverage of Foster Dependent
This request form allows a member to include a foster dependent on his or her contract. The form must be completed by the subscriber and forwarded to Preferred Care along with legal documentation, such as a court order or county Social Services documentation.
Request for Restriction on the Use or Disclosure of Information
On this form you can request that Preferred Care restrict the use of your medical or financial information even further than it does normally.
Form to complete to confirm full time student status for dependent children over 19 whose policy requires full time student status to remain eligible with Preferred Care. Subscriber completes the application then forwards it to Preferred Care. Student status may also be confirmed via e-mail with or without use of this form.
Form members use if they or their spouse are actively employed, over 65 and Medicare eligible if they would like to stay on their Preferred Care Commercial Health Plan rather than switching to a Preferred Care Gold Health Plan. The member (or spouse's) employer must have more than 20 employees to choose this option.
TriVantage Reimbursement Claim Form
Use this form when seeking reimbursement for your Active Lifestyles or Family Focus benefits.