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.

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Forms

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

  • Health Insurance Claim Form - EmblemHealth, HIP, GHI

    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 - EmblemHealth

    This form allows you to submit claims for EmblemHealth prescriptions.

  • 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 - GHI, EmblemHealth

    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. Members who have an On Exchange plan must contact NYSOH at 1‑855‑355‑5777 to elect coverage under the Young Adult rider.

  • 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, GHI

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

  • Student Verification Form for NYS Enrollees Only - GHI

    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.

  • Medical Records Transfer Request - HIP

    When members are changing their primary care physicians (PCPs) from different medical centers or private physician offices, this form should be used.

  • Coordination of Benefits EmblemHealth - EmblemHealth

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

  • Coordination of Benefits HMO - HIP

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

  • Coordination of Benefits PPO - GHI

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

  • Fitness Facility Member Verification Form - EmblemHealth

    If your benefit plan includes the ExerciseRewardsTM Program, use this form to verify you are a member at a fitness facility.

  • Get Paid Back for Your Fitness Facility Dues - EmblemHealth

    With the ExerciseRewardsTM program, you can enjoy the benefits of exercise and get paid back for your dues.

  • Payout Request Form Log - EmblemHealth

    If your benefit plan includes the ExerciseRewardsTM Program, use this form to get back up to $200 of your membership dues.

  • Dental Claim form

    Use this form to submit dental claims to EmblemHealth

Quick Start Guides

Get easy online access to your Quick Start Guide to help you get the most out of your health plan.

 

Essential

 

HMO Millennium

 

HMO Select Care

 

EPO Qualified Health

 

HMO Millennium

 

HMO Qualified Health

 

HMO Qualified Health with Acupuncture

 

HMO Select Care

 

PPO Qualified Health

 

ConsumerDirect EPO

 

ConsumerDirect PPO

 
 

EPO Value

 

EPO Value HDHP (High Deductible Health Plan)

 

GHI HMO

 

Health Essentials Plus EPO

 

HIP HMO Preferred

 

HIP Prime HMO

 

HIP Prime POS

 

HIP Prime PPO

 

HIP Select PPO

 

HIPaccess I

 

HIPaccess II

 

HMO Plus

 

HMO Preferred Plus

 

InBalance EPO

 

InBalance PPO

 
 

PPO Value

 

Child Health Plus

 

Enhanced Care

 

Enhanced Care Plus


 

2021 Individual and Family Plan Documents

Access easy-to-read summaries of the most important things to know about your plan.


 

2021 Group Plan Documents

Access easy-to-read summaries of the most important things to know about your plan.


 

Formularies

List of Covered Drugs

  • 2020 Enhanced Care (Medicaid) and Enhanced Care Plus (HARP) Formulary


 

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

Preauthorization Check Tool

EmblemHealth is offering an easy way for you to see if your procedure requires preauthorization.  

It’s a Preauthorization Check tool for members who have our HMO plans.   Before using the tool, ask your doctor for the Procedure Code, also known as CPT or HCPCS code, and your Diagnosis code and Place of Service code—where the services will be performed.  Once you have this information, click on the Preauthorization Check button below.  Enter the information to see if you need to get a preauthorization ahead of your procedure. 

Remember, you never have to get a preauthorization for emergency services. 

If you have a PPO plan or if you have other questions, you can always check your plan documents, or call the number on your ID card.