Title
Description
Network
This form is used when seeking reimbursement for non-participating providers
EmblemHealth, GHI, 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
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
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