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)
  • EmblemHealth Large Group Applications (for groups with 101 or more full-time equivalent eligible employees)
  • Transaction Form for Group Accounts
    This form should be used for enrolling, terminating or changing the status of a subscriber.

  • 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.

  • Health Benefits Waiver Form
    This form should be completed by an employee who is declining enrollment in the plan.

New Group Sizes - Effective January 1, 2016

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New group sizes will be defined as:

Small Group = 100 or fewer full-time equivalent eligible employees

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

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