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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?

What are you looking for?

 

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.

  • 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 - 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

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

  • Student Verification Form for NYS Enrollees Only

    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
 
 

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

How to determine if your medical procedure requires preauthorization

Want to see if your procedure requires a preauthorization? We have a resource for that.

It’s a quick form that tells you whether a preauthorization is needed for specific services. 

You will need your member ID and the following details from your provider before you can use the tool:

  • Procedure Code—also known as CPT or HCPCS Code
  • Diagnosis Code
  • Place of Service—where the services will be performed. 

Click the button below to launch the tool and enter the requested 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 any questions, please contact us here or at the number on your ID card.  

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