Forms

Choose from the list of NYCE PPO forms or search for a specific form to download. If you have any questions about which forms or documents you may need, please call Member Services at 212-501-4444 (TTY: 711).

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pdf Post Service Appeal Request Form (UMF0010-NYCE)
pdf Pre-Service Appeals - Designation of Authorized Representative (UMF0011-NYCE)
pdf Pre-Service Appeals - Designation of Authorized Representative – Spanish (UMF0011-NYCE-SP)
pdf Pre-Service Appeals - Designation of Authorized Representative – Chinese (UMF0011-NYCE-MAN)
pdf Post-Service Appeals - Designation of Authorized Representative (UMF0018-NYCE)
pdf Post-Service Appeals - Designation of Authorized Representative – Spanish (UMF0018-NYCE-SP)
pdf Post-Service Appeals - Designation of Authorized Representative – Chinese (UMF0018-NYCE-MAN)
pdf Request for Other Medical Insurance Information Form (UMF0021-NYCE)
pdf Medical Claim Submission Form (UMF0022-NYCE)
pdf Medical Claim Submission Form – Chinese (UMF0022-NYCE-MAN)
pdf Authorization for Release of Health Information (UMF0023-NYCE)
pdf Authorization for Release of Health Information – Spanish (UMF0023-NYCE-SP)
pdf Authorization for Release of Health Information – Chinese (UMF0023-NYCE-MAN)
pdf Request to Amend Protected Health Information (UMF0086-NYCE)
pdf Request to Amend Protected Health Information – Spanish (UMF0086-NYCE-SP)
pdf Request to Amend Protected Health Information – Chinese (UMF0086-NYCE-MAN)
pdf Request for an Accounting of Non-routine Disclosures of Protected Health Information (PHI) (UMF0088-NYCE)
pdf Request for an Accounting of Non-routine Disclosures of Protected Health Information (PHI) – Spanish (UMF0088-NYCE-SP)
pdf Request for an Accounting of Non-routine Disclosures of Protected Health Information (PHI) – Chinese (UMF0088-NYCE-MAN)
pdf Request for Access to Protected Health Information (PHI) (UMF0089-NYCE)
pdf Request for Access to Protected Health Information (PHI) – Spanish (UMF0089-NYCE-SP)
pdf Request for Access to Protected Health Information (PHI) – Chinese (UMF0089-NYCE-MAN)
pdf Privacy Complaint Form (UMF0097-NYCE)
pdf Continuity of Care Form (UMF0005-NYCE)
pdf Continuity of Care Form – Spanish (UMF0005-NYCE-SP)
pdf Continuity of Care Form – Chinese (UMF0005-NYCE-MAN)
pdf Transition of Care Form (UMF0065-NYCE)
pdf At Home COVID-19 Test Reimbursement Form (UMF0007-NYCE)
pdf Contraceptive Management Mobile Application Reimbursement Form (UMF0031-NYCE)
pdf Travel and Lodging Reimbursement Form (UMF0177-NYCE)
PDF Provider Nomination Form
Disability Status Request Form (UMF0178)
Student Verification Form (UMF0179)
pdf Provider Remittance Advice (RA) Form (UMF0025-NYCE)
pdf Varicose Veins Clinical Request Form (UMF0050-NYCE)
pdf CPAP/BIPAP Request Form (UMF0042-NYCE)
Provider Medical Claim Submission Form (HCFA1500)
pdf Confidential Communications (UMF0180)
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