Below you will find forms that you may need. To submit a form or supply supporting documents, follow the instructions specific to each form.

EmblemHealth Small Group Applications

- For groups with 100 or fewer full-time equivalent eligible employees

Complete this application before enrolling a small group plan

HMO Small Group Application Download (PDF)
EmblemHealth HMO plan (excluding EmblemHealth Healthy NY) Download (PDF)
Healthy NY HMO Small Group Application
Healthy NY HMO plan Download (PDF)

EmblemHealth Large Group Applications

- For groups with 101 or more full-time equivalent eligible employees

Complete this application before enrolling a large group plan

HIP Application for Large Groups Download (PDF)
HIP-underwritten large group plan Download (PDF)
HIPIC Application for Large Groups
HIPIC-underwritten large group plan Download (PDF)
GHI Application for Large Groups
GHI-underwritten large group plan Download (PDF)

Transaction Form for Group Accounts

This form should be used for enrolling, terminating or changing the status of a subscriber.

Transaction Form for Group Accounts Download (PDF)

Member Change Form for Group Accounts

This form should be used to report the change of status or termination of one or more subscribers. Note, this takes the place of the form previously known as the “HIP Transmittal Form” – it now applies to GHI-underwritten plans, as well as HIP- and HIPIC-underwritten plans.

Member Change Form for Group Accounts Download (PDF)

Health Benefits Waiver Form

This form should be completed by an employee who is declining enrollment in the plan.

Health Benefits Waiver Form Download (PDF)

New Group Sizes - Effective January 1, 2016

Broker Focus March April Thumbnail

New group sizes will be defined as:

Large Group = more than 100 full-time equivalent eligible employees

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