Skip Navigation

繁體中文 EN ESPAÑOL
×
Search Our Site
Search
tier-members-forms

FORMS

Search by plan for the forms you need.

 
Find a Doctor or Hospital

Locate a doctor, hospital or other health care services near you.

Search Now
Health & Wellness

At EmblemHealth we’re dedicated to helping you stay healthy, get well and live better.

Learn More
Pharmacy

Learn about EmblemHealth’s pharmacy benefits.

Learn More
Flu, Pneumonia And Shingles Vaccines Available at Retail Pharmacies
Learn More
ABC's of Health Care Reform

EmblemHealth has simplified health care reform and mapped out what you need to know.

Learn more
Information About Our Proposed 2015 Rates

We have prepared a plain-English summary that provides an explanation of the reasons why premium rate changes are being requested for our Large Group HMO plans.

Learn More
Considering EmblemHealth?

Please contact us or call EmblemHealth sales at

1-877-411-3625
Title
Description
Network
This form allows you to submit a dental claim having visited a nonparticipating dentist. All participating network dentists must submit claims forms directly to GHI for processing.
GHI
Patient and Physician Statement Claim Form for HIP members
HIP
This form allows you to submit claims for EmblemHealth prescriptions.
EmblemHealth
For members who have the HIP plan. For members who have additional dental benefits beyond HIP's basic preventive dental plan, Medicaid and Child Health Plus.
HIP
When using a nonparticipating provider for routine vision services, i.e., eye exams, lenses, frames and/or contacts, please have this form completed by the provider that rendered the services.
GHI
The health club reimbursement form can only be used by eligible members enrolled in a HIP Classic HMO group, or in a small group HIP Select EPO or HIP Select PPO plan.
HIP

You are now leaving EmblemHealth

Please check the Privacy Statement of the site to which you are going.

Click to Continue ×

You are now leaving the Medicare section of the EmblemHealth website.

Click to Continue ×

Your member ID # is on the front of your ID card.

In most cases, if you are the policy holder, you can also use your Social Security Number to register.