Forms & Downloads
Welcome to the Employer Form Library. Here you will find forms for your employees and for managing your account with GHI.
GHI Forms
Name/Description
Format/Size
Coordination of Benefits Questionnaire
This form assists you in the coordination of benefits received under more than one health insurance program by you or any dependent. Coordinating benefits helps to contain the cost of health care and can save you out-of-pocket expenses. Please return this completed form to GHI so that we can assist you in this effort. (2 pages)
This form assists you in the coordination of benefits received under more than one health insurance program by you or any dependent. Coordinating benefits helps to contain the cost of health care and can save you out-of-pocket expenses. Please return this completed form to GHI so that we can assist you in this effort. (2 pages)
PDF/29KB
Dental Claim Form
This form allows you to submit a dental claim having visited a non-participating dentist. Please complete this form to indicate the services that you or your dependent has received. Please indicate the patient's name and date of birth along with the policyholder's identification number. It is required that you attach the itemized bill to this form.
All participating network dentists must submit claims forms directly to GHI for processing. (2 pages)
This form allows you to submit a dental claim having visited a non-participating dentist. Please complete this form to indicate the services that you or your dependent has received. Please indicate the patient's name and date of birth along with the policyholder's identification number. It is required that you attach the itemized bill to this form.
All participating network dentists must submit claims forms directly to GHI for processing. (2 pages)
PDF/52KB
Dependent Student Certification Form (PPO)
If your dependent is a student, use this form to prove enrollment in a higher education school. A full-time dependent student is a person who meets all of the following conditions: He/she is at least 19 years of age, unmarried, receives at least half of his/her support from the employee or member, and is enrolled full-time in an accredited secondary or preparatory school or college. (1 page)
If your dependent is a student, use this form to prove enrollment in a higher education school. A full-time dependent student is a person who meets all of the following conditions: He/she is at least 19 years of age, unmarried, receives at least half of his/her support from the employee or member, and is enrolled full-time in an accredited secondary or preparatory school or college. (1 page)
PDF/88KB
Dependent Student Verification Form (HMO)
If your dependent is a student, use this form to prove enrollment in a higher education school. A full-time dependent student is a person who meets all of the following conditions: He/she is at least 19 years of age, unmarried, receives at least half of his/her support from the employee or member, and is enrolled full-time in an accredited secondary or preparatory school or college. (1 page)
If your dependent is a student, use this form to prove enrollment in a higher education school. A full-time dependent student is a person who meets all of the following conditions: He/she is at least 19 years of age, unmarried, receives at least half of his/her support from the employee or member, and is enrolled full-time in an accredited secondary or preparatory school or college. (1 page)
PDF/37KB
Durable Medical Equipment Claim Form
Durable Medical Equipment includes: hospital beds, oxygen and oxygen equipment, walkers, wheelchairs, and other medically necessary durable equipment and supplies. Standard HCFA-1500 form. (2 pages)
Durable Medical Equipment includes: hospital beds, oxygen and oxygen equipment, walkers, wheelchairs, and other medically necessary durable equipment and supplies. Standard HCFA-1500 form. (2 pages)
PDF/199KB
Prescription Drug Claim Forms
Members should check their ID card. If there is an Express Scripts logo on the ID card, the Express Scripts, Inc. prescription drug claim form below should be used. If GHI Pharmacy Services or GHI HMO Pharmacy Services is on the back of the ID card, the GHI or GHI HMO Pharmacy Services prescription drug claim form below should be used.
| Pharmacy Managed by Express Scripts |
Pharmacy Managed by GHI or GHI HMO Pharmacy Services |
 |
 |
Large Employer Group Application
This application should be completed prior to enrolling a large employer group with GHI. (4 pages)
This application should be completed prior to enrolling a large employer group with GHI. (4 pages)
PDF/1.2MB
Medical Claim Form (HCFA-1500 form)
This form is for non-participating providers seeking claims with GHI. Please complete this form and attach an itemized bill, which must be on the provider's letterhead. The bill must contain the following information:
This form is for non-participating providers seeking claims with GHI. Please complete this form and attach an itemized bill, which must be on the provider's letterhead. The bill must contain the following information:
- Name and address (of servicing provider)
- Date of service
- Location service was rendered
- Charge for each service
- Diagnosis
PDF/199KB
Optical Claim Form
When using a non-participating provider for routine vision services i.e., eye exam, lenses, frames and/or contacts, please have this form completed by the provider that rendered the services. (2 pages)
When using a non-participating provider for routine vision services i.e., eye exam, lenses, frames and/or contacts, please have this form completed by the provider that rendered the services. (2 pages)
PDF/199KB
Prior Authorization Form (HMO)
Prior Authorization is intended to ensure that the requested service is covered by the member's benefit, that the provider of service is participating, and that the services are medically necessary. Services will also be reviewed to ensure that the most appropriate setting is being utilized and to identify those members who may benefit from our care Management programs. Required prior authorization can be obtained by faxing this Prior Authorization Form with supporting documentation to GHI HMO at 877-508-2643. (1 page)
Prior Authorization is intended to ensure that the requested service is covered by the member's benefit, that the provider of service is participating, and that the services are medically necessary. Services will also be reviewed to ensure that the most appropriate setting is being utilized and to identify those members who may benefit from our care Management programs. Required prior authorization can be obtained by faxing this Prior Authorization Form with supporting documentation to GHI HMO at 877-508-2643. (1 page)
PDF/74KB
Psychiatric Claim Form
For Behavioral Management Program claims with psychiatrists, psychologists, social workers and other similar providers. Standard HCFA-1500 form. (2 pages)
For Behavioral Management Program claims with psychiatrists, psychologists, social workers and other similar providers. Standard HCFA-1500 form. (2 pages)
PDF/199KB
Radiology Precertification (HMO)
Precertification by CareCore is required for the following procedures when performed on an outpatient basis in Outpatient Hospital Facilities, Free Standing Radiology Facilities, and Non-Radiology Office-Based Settings: CT, MRI, MRA, Nuclear Medicine, PET Scans and Obstetrical Ultrasounds (in excess of three (3) during a pregnancy). To ensure that the precertification process fully considers patient symptoms and clinical findings, GHI HMO requires that the referring physician obtain the precertification from CareCore. (2 pages)
Precertification by CareCore is required for the following procedures when performed on an outpatient basis in Outpatient Hospital Facilities, Free Standing Radiology Facilities, and Non-Radiology Office-Based Settings: CT, MRI, MRA, Nuclear Medicine, PET Scans and Obstetrical Ultrasounds (in excess of three (3) during a pregnancy). To ensure that the precertification process fully considers patient symptoms and clinical findings, GHI HMO requires that the referring physician obtain the precertification from CareCore. (2 pages)
PDF/65KB
Refusal of Insurance Card
Form by which group members request waver of group coverage. Please mail completed form to your GHI General Agent. (1 page)
Form by which group members request waver of group coverage. Please mail completed form to your GHI General Agent. (1 page)
PDF/59KB
Small Group Application Cover Sheet
This coversheet must accompany the Small Employer Group Application (below). (1 page)
This coversheet must accompany the Small Employer Group Application (below). (1 page)
PDF/278KB
Small Employer Group Application
This application should be completed prior to enrolling a small employer group with GHI. (6 pages)
This application should be completed prior to enrolling a small employer group with GHI. (6 pages)
PDF/278KB
Transaction Form for Group Accounts
This form should be used for enrolling, terminating or changing the status of a subscriber. (2 pages)
This form should be used for enrolling, terminating or changing the status of a subscriber. (2 pages)
PDF/47KB
Claim forms can be viewed and printed as PDF files on all major computer platforms. You will need the Adobe
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