These forms can be used for various requests. Please follow the instructions for completing and returning forms.
For All Plans
Authorization for Release of Protected Health Information (PHI) - English | Spanish | Chinese
New York State Out-of-Network Surprise Medical Bill Assignment of Benefits FormUse this form if you receive a surprise bill for health care services and want the services to be treated as in-network.
Child Health Plus
CHP Claim FormChild Health Plus Members should use this form if you paid out-of-pocket for a drug covered by your pharmacy benefit for which you would like to be considered for reimbursement.
CHP DIRECT PAYMENT AUTHORIZATION Form - English Child Health Plus subscribers should use this form to authorize Affinity Health Plan to deduct monthly premium payments from their bank account.
CHP AUTORIZACIÓN DE PAGO DIRECTO Formulario - en español Los suscritos a Child Health Plus deben usar este formulario para autorizar que Affinity Health Plan deduzca los pagos de la prima mensual de su cuenta bancaria.
CHP CANCELLATION OF DIRECT DEBIT Form - English Child Health Plus subscribers should use this form to cancel their monthly direct debit premium deduction from their bank account.
Formulario - CANCELACIÓN DEL DÉBITO DIRECTO DE CHP - en español Los suscritos a Child Health Plus deben usar este formulario para cancelar la deducción del debito directo de su cuenta bancaria para la prima mensual.
Affinity Qualified Health Plans
QHP Pharmacy Mail Order Form