Important Resources

Share the value of EmblemHealth’s plans and services with your clients. To request a complimentary stock of professionally printed versions of any of these pieces for your office, please contact your EmblemHealth representative.

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HMO Small Group Applications

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

  • HMO Small Group Application

    EmblemHealth HMO Plan (excluding EmblemHealth Healthy NY)

  • Healthy NY HMO Small Group Application

    Healthy NY HMO Plan


Group Resources

Access all the materials you need for groups of all sizes.


EmblemHealth Large Group Applications

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

  • HIP Application for Large Groups

    HIP-underwritten large group plan

  • HIPIC Applications for Large Groups

    HIPIC-underwritten large group plan

  • HIPIC EPO Value Applications for Large Groups

    EPO Value HIPIC-underwritten plan

  • GHI Application for Large Groups

    EPO Value HIPIC-underwritten plan


  • 2019 Small Group Underwriting Guidelines


  • Employee HSA Application

  • Employer HSA Application


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


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 underwritten plans, as well as HIP-and HIPIC-underwritten plans.

  • Member Change Form for Group Accounts


  • Caring For Your Small Business

  • Guide to SHOP

  • Go Paperless With MyEmblemHealth

  • Telemedicine through Teledoc

  • Using your Telemedicine Benefit

  • Acupuncture

  • Dental Plans: Did You Know

  • Healthy Discounts

  • ASPCA Pet Health Insurance

  • Small Group Prime and Select Care Network brochure

  • Health Savings Account Member Education Site

  • 2019 Small Group Pharmacy at a Glance

  • 2019 EmblemHealth Platinum Premier Benefits Summary

  • 2019 EmblemHealth Platinum Premier Member Schedule

  • 2019 EmblemHealth Platinum Premier Summary of Benefits and Coverage

  • 2019 EmblemHealth Platinum Premier Dental

  • 2019 EmblemHealth Platinum Choice Benefits Summary

  • 2019 EmblemHealth Platinum Choice Member Schedule

  • 2019 EmblemHealth Platinum Choice Summary of Benefits and Coverage

  • 2019 EmblemHealth Platinum Choice Dental

  • 2019 EmblemHealth Gold Premier Benefits Summary

  • 2019 EmblemHealth Gold Premier Member Schedule

  • 2019 EmblemHealth Gold Premier Summary of Benefits and Coverage

  • 2019 EmblemHealth Gold Premier Dental

  • 2019 EmblemHealth Gold Premier 1 Benefits Summary

  • 2019 EmblemHealth Gold Premier 1 Member Schedule

  • 2019 EmblemHealth Gold Premier 1 Summary of Benefits and Coverage

  • 2019 EmblemHealth Gold Premier 1 Dental

  • 2019 EmblemHealth Gold Plus Benefits Summary

  • 2019 EmblemHealth Gold Plus Member Schedule

  • 2019 EmblemHealth Gold Plus Summary of Benefits and Coverage

  • 2019 EmblemHealth Gold Plus Dental

  • 2019 EmblemHealth Gold Plus 1 Benefits Summary

  • 2019 EmblemHealth Gold Plus 1 Member Schedule

  • 2019 EmblemHealth Gold Plus 1 Summary of Benefits and Coverage

  • 2019 EmblemHealth Gold Plus 1 Dental

  • 2019 EmblemHealth Gold Choice Benefits Summary

  • 2019 EmblemHealth Gold Choice Member Schedule

  • 2019 EmblemHealth Gold Choice Summary of Benefits and Coverage

  • 2019 EmblemHealth Gold Choice Dental

  • 2019 EmblemHealth Gold Value Benefits Summary

  • 2019 EmblemHealth Gold Value Member Schedule

  • 2019 EmblemHealth Gold Value Summary of Benefits and Coverage

  • 2019 EmblemHealth Gold Value Dental

  • 2019 EmblemHealth Silver Premier Benefits Summary

  • 2019 EmblemHealth Silver Premier Member Schedule

  • 2019 EmblemHealth Silver Premier Summary of Benefits and Coverage

  • 2019 EmblemHealth Silver Premier Dental

  • 2019 EmblemHealth Silver Premier 1 Benefits Summary

  • 2019 EmblemHealth Silver Premier 1 Member Schedule

  • 2019 EmblemHealth Silver Premier 1 Summary of Benefits and Coverage

  • 2019 EmblemHealth Silver Premier 1 Dental

  • 2019 EmblemHealth Silver Plus Benefits Summary

  • 2019 EmblemHealth Silver Plus Member Schedule

  • 2019 EmblemHealth Silver Plus Summary of Benefits and Coverage

  • 2019 EmblemHealth Silver Plus Dental

  • 2019 EmblemHealth Silver Plus 1 Benefits Summary

  • 2019 EmblemHealth Silver Plus 1 Member Schedule

  • 2019 EmblemHealth Silver Plus 1 Summary of Benefits and Coverage

  • 2019 EmblemHealth Silver Plus 1 Dental

  • 2019 EmblemHealth Silver Choice Benefits Summary

  • 2019 EmblemHealth Silver Choice Member Schedule

  • 2019 EmblemHealth Silver Choice Summary of Benefits and Coverage

  • 2019 EmblemHealth Silver Choice Dental

  • 2019 EmblemHealth Silver Value Benefits Summary

  • 2019 EmblemHealth Silver Value Member Schedule

  • 2019 EmblemHealth Silver Value Summary of Benefits and Coverage

  • 2019 EmblemHealth Silver Value Dental

  • 2019 Bronze Plus HSA Benefits Summary

  • 2019 Bronze Plus HSA Member Schedule

  • 2019 Bronze Plus HSA Summary of Benefits and Coverage

  • 2019 Bronze Plus HSA Dental

  • 2019 EmblemHealth Bronze Value Benefits Summary

  • 2019 EmblemHealth Bronze Value Member Schedule

  • 2019 EmblemHealth Bronze Value Summary of Benefits and Coverage

  • 2019 EmblemHealth Bronze Value Dental

  • 2019 EmblemHealth Healthy NY Gold Benefits Summary

  • 2019 EmblemHealth Healthy NY Gold Member Schedule

  • 2019 EmblemHealth Healthy NY Gold Summary of Benefits and Coverage

  • 2019 EmblemHealth Healthy NY Gold Dental

  • Small Group Rates

  • 2019 HNY Rates Sheet

  • Small Group Dental Information

    Groups of 5 - 50 Eligible Employees (Contributory)

  • Small Group Dental Information

    Groups of 5 - 50 Eligible Employees (Voluntary)

  • Small Group Dental Information

    Groups of 2 - 4 Eligible Employees

  • Small Group Dental Information

    Preferred Dental with $1000 yearly maximum

  • Small Group Dental Information

    Preferred Dental with $1500 yearly maximum



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


  • 2019 Small Group Application

  • 2019 HNY Application

  • 2019 Transaction Form

  • 2019 Small Group Commission Schedule

  • 2019 Small Group HMO Certificate

  • 2019 Small Group Underwriting Guidelines

  • 2019 Small Group Business Checklist

  • 2019 Small Group New Business Late Submission Form


  • EmblemHealth Dental Brochure

  • Preventive Dental Access Program

  • Dental Access

  • Preferred Dental

  • Preferred Plus Dental

  • HIP Preventive Dental

  • Did You Know About EmblemHealth Preferred Dental?