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Title
Description
Network
Your out-of-network practitioner should give you an itemized red CMS HCFA-1500 medical claim form at the end of your visit. If they are unable to do so, download and print the HCFA-1500 form.
EmblemHealth, GHI PPO, HIP
This form allows you to submit claims for EmblemHealth prescriptions.
EmblemHealth
Authorization, Verification and Certification Forms Authorization to Use and Disclose Protected Health Information A written authorization is required for your plan to share a member's protected health information with anyone, except as required or permitted by law.
GHI PPO, EmblemHealth, HIP
Authorization to Use and Disclose Protected Health Information in Spanish
EmblemHealth, GHI PPO, HIP
Use this form if you are a plan member or the child of a plan member who is now a young adult and wants to be covered under your parent's plan.
GHI PPO, EmblemHealth
If your dependent is a student, use this form to prove enrollment in a higher education school.
EmblemHealth, GHI PPO
Use this form to maintain coverage for your dependent who has not married, is disabled, and became disabled before reaching the age at which dependent coverage would otherwise end. NYSHIP members must obtain the Statement of Disability form (PS-451) from their health benefits administrator.
GHI PPO, EmblemHealth, HIP
This form assists you in the coordination of benefits received under more than one health insurance program by you or any dependent.
EmblemHealth

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