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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For groups with 101 or more full-time equivalent eligible employees
This form should be used for enrolling, terminating, or changing the status of a subscriber.
This form should be used to report the change of status or termination of one or more subscribers. Nota: 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.
This form should be used by members to authorize us to release or disclose protected health information to someone else.