Affinity Health Plan

  • Providers template image
  • Provider Forms

    These forms are provided for your convenience, to facilitate various requests and administrative processes. Please complete and return forms as instructed.

    Medication Authorization Forms

    » Child Health Plus
    » Qualified Health Plans (QHP)
    » Medicaid
    » Medicare
    » Medical Benefit Drugs 

    Prior Authorization Form
    Use this form when requesting prior authorizations and providing a supporting statement for an exception request.

    Affinity Medical Management Prior Authorization Numbers: 
    Medicaid, CHP, Medicare: 866-247-5678
    Affinity Essential: (888) 543-9074

    Non-Participating Provider Verification Form
    Use this form if you are a non-participating provider to process your most recent authorization and/or claim.

    Waiver of Liability

    Sterilization Consent Form
    To receive reimbursement for sterilization procedures, please fax completed form and associated claim(s), according to Affinity guidelines, to Affinity’s Medical Management Pre-Certification Department Fax number (718) 794-7822. You may also access this form from the New York State Department of Health's website

    Acknowledgement of Receipt of Hysterectomy Information Form
    To receive reimbursement for hysterectomy procedures, please fax completed form and associated claim(s), according to Affinity guidelines, to Affinity’s Medical Management Pre-Certification Department Fax number (718) 794-7822. You may also access this form from the New York State Department of Health's website

    Provider Information Update Form
    To provide us with updated information (e.g., change in address, telephone number, fax number, etc.) please complete and fax this form as instructed.

    Out-of-Network Authorization Form
    Please use this form for out-of-network provider service authorization requests.

    Request to Serve as an Affinity Member’s PCP
    This form is intended to designate a PCP for Medicaid Members with HIV/AIDS

    Primary Care Physician (PCP) Change Request Form
    Affinity Health Plan wants to make it easy for our members to change primary care providers (PCPs). For this reason, this form can be used when a member would like to change his or her assigned PCP to you, you can now have the member complete and sign the form right in your office.