Title
Description
Network
This form is used when seeking reimbursement for non-participating providers
EmblemHealth, GHI, 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, EmblemHealth, HIP
Authorization to Use and Disclose Protected Health Information in Spanish
EmblemHealth, GHI, 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, EmblemHealth
If your dependent is a student, use this form to prove enrollment in a higher education school.
EmblemHealth, GHI
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, 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
If your benefit plan includes the ExerciseRewardsTM Program, use this form to verify you are a member at a fitness facility.
EmblemHealth
With the ExerciseRewardsTM program, you can enjoy the benefits of exercise and get paid back for your dues.
EmblemHealth
If your benefit plan includes the ExerciseRewardsTM Program, use this form to get back up to $200 of your membership dues.
EmblemHealth