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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 a dental claim having visited a nonparticipating dentist. All participating network dentists must submit claims forms directly to GHI for processing.
GHI PPO
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 PPO
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

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