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Plan Forms and Documents for Employers | EmblemHealth

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Employer Forms

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

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Small Group Applications

For groups with 100 or fewer full-time equivalent eligible employees. Complete this application before enrolling a small group plan.
 

Large Group Applications

For groups with 101 or more full-time equivalent eligible employees. Complete this application before enrolling a large group plan.
 

Health Savings Account Applications

 

Other Forms

  • 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.

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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.