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Forms and Documents

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Find benefit summaries, formularies (list of covered drugs), and all necessary forms to get the most out of your EmblemHealth coverage.

Looking for Medicare forms and documents?

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Forms

Find all available forms including authorization forms, claim forms and more.

  • Health Insurance Claim Form

    This form is used when seeking reimbursement for non-participating providers.

  • Patient and Physician Statement Claim Form - HIP

    Patient and Physician Statement Claim Form for HIP members

  • Pharmacy Benefit Services Prescription Drug Claim Form

    This form allows you to submit claims for EmblemHealth prescriptions.

  • NYS Standard Form to Designate a Representative to Assist with Health Insurance Authorizations, Complaints, Grievances, and Appeals

    Non-Medicare members may use this authorization form to assign a representative to file, assist, and receive information for a specific preauthorization request, complaint, grievance, or appeal. If you are looking to share a member’s protected health information for other reasons, use the Authorization to Use and Disclose Protected Health Information form. Submit via mail to EmblemHealth Customer Service Department, P.O. Box 1701, New York, NY 10023-1701 or through the member portal.

  • Authorization to Use and Disclose Protected Health Information - EmblemHealth

    Authorization, Verification and Certification Forms Authorization to Use and Disclose Protected Health Information A written authorization is required for your plan to share a member's protected health information with anyone, except as required or permitted by law.

  • Young Adult Election and Eligibility Form - HIP

    Use this form if you are a plan member or the child of a plan member who is now a young adult and wants to be covered under your parent's plan.

  • Student Verification Form - EmblemHealth

    If your dependent is a student, use this form to prove enrollment in a higher education school.

  • Disability Status Request Form - GHI, EmblemHealth, HIP

    Use this form to maintain coverage for your dependent who has not married, is disabled, and became disabled before reaching the age at which dependent coverage would otherwise end. NYSHIP members must obtain the Statement of Disability form (PS-451) from their health benefits administrator.

  • Coordination of Benefits Form

    This form assists you in the coordination of benefits received under more than one health insurance program by you or any dependent.

  • Dental Claim Form

    Use this form to submit dental claims to EmblemHealth
 
 

Member Handbooks

Your member handbook tells you how your plan coverage works to get the medical care you need and avoid out-of-pocket costs. Some sections of your member handbook have been updated. For information about the changes refer to the inserts at the end of the member handbook.

 

Important Member Resources

 
Also of Interest: 
GHI CBP   |   Member Resources Forms, Documents, & More   |   Medicare Important Plan Documents