• Change Member ID
  or Product Name

Claims & Reimbursement

• Student/Dependent Coverage Claim Form
• Medical Reimbursement Form
• TriVantage EPO Lifestyle Credit Reimbursement

• MVP Dental Claim Form
• Child Preparation Class Reimbursement
• New Hampshire Health First Wellness Verification

Enrollment & Dependent

• Member Enrollment/Change Form
• Member Enrollment/Change Form for Chamber and Multi-Employer Groups
• NH Member Enrollment/Change Form
• Disability Eligibility Determination Form - PCP
  

• Disability Eligibility Determination Form - Subscribe
• Healthy NY Re-certification Letter
• Vermont Individual Indemnity Enrollment/Change
• MVP Medical Questionnaire

Behavioral Health - Value Options

• Behavioral Health Claim Form

• Behavioral Health Authorization to Disclose Form

Student Waiver Information

• Submit a College Student Waiver online

• College Student Waiver Form

NOTE: Please allow 3-5 business days for the information to be updated in our systems. Members are required to submit student waiver information to MVP annually at the beginning of each school year.

Authorization & Referral

• Request for Health Information
• Member Formulary Exception (log-in required)

• Medication Prior Authorization

Pharmacy

• Mail Order Prescription Order Form
• Medco Prescription Drug Reimbursement Form

• Medco Health, Allergy & Medication Questionnaire
• Personal Medication List

Information Release/Restriction

• Authorization to Disclose Information Form