View Forms and Documents
Use the links below to print/view copies of our most frequently used forms. Forms marked as "East" apply to the Central New York, Central New York Southern Tier and Utica regions.
- Disclosure of Ownership & Controlling Interest Statement with FAQsOpen a PDF
- Durable Medical Equipment Upgrade FormOpen a PDF
- Eyewear Promotional Offer Acknowledgement and AgreementOpen a PDF
- Home & Community-Based Services (HCBS) Status Change FormOpen a PDF
- Home Health Care Recertification FormOpen a PDF
- Member Consent for Provider Representation During Appeal or Complaint ProcessOpen a PDF
- New York Health Care Proxy formOpen a PDF
- New York Health Care Proxy form (Spanish)Open a PDF
- Patient End-stage Renal Disease FormOpen a PDF
- PCP Selection Form (online - Recommended) or PCP Selection FormOpen a PDF
- Prenatal Incentive Program Form (online - Recommended) or Prenatal Incentive Program FormOpen a PDF
- Confirmation of Pregnancy Form - (includes Group Therapy Proposal Summary)
- Medicare Advantage Dental Benefit Plan Year 2023Open a PDF
- Request for Reconsideration Form - COB UnclearOpen a PDF
- Request for Grievance or Appeal FormOpen a PDF
- UM Initial Determination Timeframes - Commercial ProductsOpen a PDF
- UM Initial Determination Timeframes - Medicare ProductsOpen a PDF
- UM Initial Determination Timeframes - Medicaid & Safety Net ProductsOpen a PDF
- APC Pricing Dispute FormOpen a PDF
- APG Pricing Dispute FormOpen a PDF
- Billing Guidance Exceptions for Non-Enrolled Prescribers and PharmaciesOpen a PDF
- Claim Adjustment or Retraction Request FormOpen a PDF
- Provider Remittance QuestionnaireOpen a PDF
- Coordination of Benefits QuestionnaireOpen a PDF
- DRG Review Request FormOpen a PDF
- No-Fault, Workers Compensation Exhausted Benefits FormOpen a PDF
- Request for Timely Filing ReviewOpen a PDF
- Overpayment Return FormOpen a PDF
- Request for Out-of-Area Member Claim Appeal (BlueCard)Open a PDF
- Analysis and Recovery Audit - Provider Request for Review FormOpen a PDF
- Waiver of Liability StatementOpen a PDF
- Two-Day Notification and Initial Treatment PlanOpen a PDF
- Adult Behavioral Health Home and Community Based Services (BH HCBS): Prior and/or Continuing Authorization Request FormOpen a PDF
- Authorization Release FormOpen a PDF
- Authorization Release Form - (Spanish)
- Behavioral Health Procedure Codes Requiring Preauthorization
- Children and Family Treatment & Support Services Intake FormOpen a PDF
- Children's Home and Community-Based Services Intake FormOpen a PDF
- Court Ordered Treatment: Certification Form for Mental Health and Substance Use DisordersOpen a PDF
- Member Care Management Program Referral FormOpen a PDF
- Physician's Order for Personal Care Services (DOH-4359) Open a PDF
- Safety Net Form for Inpatient Preauthorization RequestsOpen a PDF
- Safety Net Form for Outpatient Preauthorization RequestsOpen a PDF
- UM Initial Determination Timeframes - Behavioral HealthOpen a PDF
Prescription Drugs
Use the Open Negotiation Notice form for Surprise Bill claims with a service date Jan-01-2022 and after, to negotiate claims priced at Qualified Payment Amount.
- Open Negotiation Notice formOpen a pdf
All required details must be provided. Email the completed form to surprisebillnegotiationexcellus@excellus.com
Additional Information
Federal No Surprise Bill
New York Surprise Bill
Questions
Federal Employee Plan (FEP), call 1-800-584-6617
All others, call 1-800-920-8889
