These forms are provided for your convenience, to facilitate various requests and administrative processes. Please complete and return forms as instructed.
- Medication Authorization Forms
- Prior Authorization Form
Use this form when requesting prior authorizations, in- and out-of-network, 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.
- 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.