Broker Forms
Protected Health Information Forms
- Use And Disclose Protected Health Information Authorization Form
- Release Confidential HIV-Related Health Information Authorization Form
- Use And Disclose Psychotherapy Notes Authorization Form
- MyFund An Innovative New Consumer Directed Healthplan
- Employer Group Forms
Association Forms
EH/HIP – mini-COBRA/ARRA Forms & Notice- Mini-COBRA/ARRA Employer Group Cover Letter
- Employer Group Attestation
- NYS Continuation Coverage Election Notice
For assistance in filling out any of the forms, call 1-800-HIP-TALK.
Download the free Adobe® Acrobat® Reader, version 3.0 or higher, in order to view and print the information.
Use and Disclose Protected Health Information Authorization Form
A written authorization is required for HIP to share a member's protected health information with anyone, except as permitted by law. This form authorizes the release of general health information and may not be used to authorize the release of HIV-related information or psychotherapy notes that are recorded and kept separately by a mental health professional.[ download here | back to top ]
Release Confidential HIV-Related Health Information Authorization Form
A written authorization is required for HIP to share a member's protected health information with anyone, except as permitted by law. This form is to be used to authorize the release of confidential HIV-related information.[ download here | back to top ]
Use and Disclose Psychotherapy Notes Authorization Form
A written authorization is required for HIP to share a member's protected health information with anyone except as permitted by law. This form is to be used to authorize the release of psychotherapy notes that are recorded and kept separately by a mental health professional, documenting the contents of a conversation during a counseling session.[ download here | back to top ]
MyFund Marketing Information
MyFund is HIP’s new innovative Consumer Directed Healthcare Product. It combines a Health Reimbursement Account with a high deductible Select EPO or PPO. To learn more about it, download the attached presentation which describes the features in detail.[ download here | back to top ]
Employer Group Forms
- Underwriting Guideline Checklist
- Waiver form
- Group Application
- Prime EPO for Large Groups
- Prime EPO for Small Groups
- HIP Prime for Large Groups
- HIP Access I for Large Groups
- HIP Prime for Small Groups
- HIP Access I for Small Groups
- HIPIC Select EPO for Large Groups
- HIPIC Select EPO for Small Groups
- HIPIC Select PPO for Large Groups
- HIPIC Select PPO for Small Groups
- HIP Prime POS for Large Groups
- HIPaccessII for Large Groups
- HIP Prime POS for Small Groups
- HIPaccessII for Small Groups
- HIP PPO for Large Groups
- HIP PPO for Small Groups
- Smart Start EPO for Large Groups
- Smart Start EPO for Small Groups
