Quick Links
Logo

FORMS

When accessing or downloading online forms, you agree to release, indemnify and hold harmless Ameritas Life Insurance Corp. of New York and/or its subsidiaries for any damage or liability encountered from using these forms. Please remember to keep only the most current Ameritas of New York forms on file.

Privacy Forms

Authorization for Release of Protected Health Information
To be in compliance with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, a patient/guardian/personal representative must complete this form to authorize disclosure of confidential health information about any insured member. Please print and complete the form and return it to us at:

Privacy Office
PO Box 81889
Lincoln, NE 68510
Fax: 402-309-2580

English Authorization for Release of Protected Health Information
Spanish Authorization for Release of Protected Health Information
 

HIPAA Individual Rights Forms 
Our HIPAA Privacy Notice describes members/insured's rights with respect to the protected health information (PHI) we maintain.
All requests about these rights need to be made in writing using the PHI forms.

Protected Health Information Forms


Claim Forms
English Dental Claim Form (fillable pdf)
Spanish Dental Claim Form 
Ameritas of New York Vision Claim Form (fillable pdf) - for Vision Perfect plans, Dental plans with LASIK, FUSION plans and
Dental plans with Exam Only benefit

Spanish Ameritas of New York Vision Claim Form

Enrollment Forms
Use our enrollment forms to enroll, change your name, add/drop dependents or waive coverage.

Choose from Dental/Vision, Dental Only or Vision Only. If your plan is High/Low, choose the Dental/Vision High/Low form and
be sure to select which option you want.
We also have Spanish versions of our two most popular Dental/Vision forms.
Dental Only (fillable PDF)
Spanish Dental/Vision

State-Specific ADA Claim Forms

Some states require you to use the ADA Claim Form for paper submission of dental claims.
If you have services performed in one of the following states, you must use the ADA form: 
GA, ID, IL, IN, KY, LA, MD, MN, MO, MT, NC, ND, NJ, NV, NY, OH, OK, SD, TN, TX, VT, WI, WY.

This listing of states is subject to change due to state regulations.   
ADA Dental Claim Form
 

New Jersey Application to Appeal a Claims Determination
You have the right to appeal our claims determination(s) or appeal an apparent lack of activity on a claim you submitted. 
New Jersey Application to Appeal a Claims Determination


Dependent Status Forms

Exception to Dependent Child Definition 
If you have a non-traditional dependent under your care, submit the form below to determine if they qualify for dependent status.
English Request for Dependent Child Exception
Spanish Request for Dependent Child Exception
 


Enroll Dependent Under Disabled Status 

If your child is over the dependent age (as specified in your plan) and is considered fully disabled, have your child's physician complete this form.
English Statement of Health
Spanish Statement of Health


Appointment Application/Business Associate Addendum


State Specific Appeals Rights
View the states that require state specific appeals rights information and forms.

 

Source: