Small Group Applications
- For groups with 100 or fewer full-time equivalent eligible employees
- HMO Small Group Application
Complete this application before enrolling a small group in any EmblemHealth HMO plan (excluding EmblemHealth Healthy NY).
- Healthy NY HMO 2017 Small Group Application
Complete this application before enrolling a small group in the Healthy NY HMO plan.
Large Group Applications
- For groups with 101 or more full-time equivalent eligible employees
Managing Members – Forms
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.