Forms

Groups

Attestation Letter Download (PDF)

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) 

    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 plan Download (PDF)
    HIPIC Application for Large Groups
    HIPIC-underwritten plan other than EPO Value Download (PDF)
    HIPIC EPO Value Application for Large Groups
    EPO Value HIPIC-underwritten plan Download (PDF)
    GHI Application for Large Groups
    GHI-underwritten plan Download (PDF)

      Managing Members – Forms

      Employee HSA Online E-Application

      Health Savings Account Download (PDF)
      Employee HSA Application Download (PDF)
      Employer HSA Application 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)

      Authorization to Use and Disclose Protected Health Information

      This form should be used by members to authorize us to release or disclose protected health information to someone else.

      Authorization to Use and Disclose Protected Health Information Download (PDF)

        NOTE: The forms on this page are available as Adobe® PDF files. You will need Adobe Reader®, a free program from Adobe, to download and print the forms.  Click here to get Adobe Reader now. Follow Adobe’s instructions for download and installation. Print out the appropriate form and mail it to the address listed on the form.