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Claim Form for Members (Medical HCFA-1500 form)

Claims Address Your completed claim form should be sent to the address on the back of your member ID card.

How can I obtain a medical claim form?

If you are a member who may receive services from an out-of-network practitioner, your practitioner should give you an itemized red CMS 1500 medical claim form at the end of your visit. Or, the practitioner may either submit the form electronically to EmblemHealth or mail the completed red form to the address on the back of your member identification card.

If the out-of-network practitioner cannot generate a CMS 1500 medical claim form, please download and print the form.

If you are a health care professional, you need to secure the red forms from any of the many vendors who supply this form. Contact your practice management system vendor or search the Web for "CMS 1500" to get a list of suppliers.

Do I have to use a form that is in red or can I use a form that is copied or printed in black?

Red forms are the industry standard and many payers, including EmblemHealth, are evaluating not accepting claims submitted in black ink. The red claim form allows claim scanners to seamlessly accept and process the claim. This results in a clean image that is faster to process and error-free.

NOTE: The forms on this page are available as Adobe® PDF files. You will need Adobe Reader®, a free program from Adobe, to download and print the forms. Click here to get Adobe Reader now. Follow Adobe's instructions for download and installation. Print out the appropriate form and mail it to the address listed on the form.