Forms

Important Notice on MAPD HMO Plan Termination Effective March 1, 2020

Effective February 29, 2020, Quality Health Plans of New York (QHPNY) will terminate its contract with the Centers for Medicare and Medicaid Services (CMS).

Quality Health Plans of New York won’t offer Medicare plans after February 29, 2020. This means coverage through Quality Health Plans of New York will end February 29, 2020.

It has been our honor to serve you. Quality of Health Plans of New York would like to thank you for the opportunity and sincerely apologizes for any inconvenience this may cause.

For more information members should refer to the notices recently mailed or call Customer Service at 1 (877) 233-7058 (TTY/TDD: 711). Until March 31st, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. and from April 1 to April 30th, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m.

You may also call 1-800-MEDICARE (1-800-633-4227). Tell them your plan isn’t going to be offered after February 2020 and you want help choosing a new plan. This toll-free help line is available 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.


This is a collection of commonly used forms.  It is not an exhaustive list.   If you are unable to find something you are looking for or have questions, please contact our Customer Service department.

Form / Document
Living Will Form

Send form to:
Quality Health Plans of New York
2805 Veterans Memorial Highway, Suite 17,
Ronkonkoma, NY 11779-7683

CMS Appointment of Representation Form (Form-CMS-1696)

Send form to:
Quality Health Plans of New York
2805 Veterans Memorial Highway, Suite 17,
Ronkonkoma, NY 11779-7683

Gym Reimbursement Form

You may receive reimbursement for these activities by completing and mailing in our Gym Reimbursement Form.  Please be sure to attach a receipt for your payment that clearly shows the name of the gym receiving your payment.  You will not be reimbursed unless you provide such a receipt.

Send form to:
Quality Health Plans of New York
Claims Department
P.O. Box 340397
Tampa, FL 33694-0397

Transportation Reimbursement Form

Send form to:
Quality Health Plans of New York
Claims Department
P.O. Box 340397
Tampa, FL 33694-0397

Mail Order Enrollment Form
Prescription Medication Prior Authorization Forms
Multi-Language Interpreter Services
Authorization for Release of Health Information
OTC Order Forms, 2020

You may also order online at https://www.IntegratedOTC.com.

 

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