Forms & Downloads
Below you will find forms that you may be directed to fill out and return to GHI or GHI HMO. Follow the instructions specific to each form in regards to submission or supplying supporting documents.
In regards to claims, when you use a participating provider, present your GHI or GHI HMO identification card at the time of your visit, pay any applicable co-payment or co-insurance charges, and that's it. The provider submits the claim for you and receives reimbursement directly from GHI.
Claim forms for other services, including out of network, are listed below. Print, complete, and submit your form directly to GHI. Most claims are processed within 10 to 15 business days from the date received.
Downloading & Printing Tips: 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.
GHI Forms
Name/Description
Format
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
Student Verification Parent Affidavit Form
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
Student Verification Parent Certification Form for NYS Enrollees Only
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
Dependent Child Incapable of Self-Sustaining Employment Certification Form
Use this form to apply for coverage beyond the limiting age for a dependent who is incapable of self-sustaining employment. (1 page)
Use this form to apply for coverage beyond the limiting age for a dependent who is incapable of self-sustaining employment. (1 page)
PDF
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
Medical Claim Form (HCFA-1500 form)
This form is for non-participating providers seeking claims with EmblemHealth. All participating network providers must submit claims forms directly to EmblemHealth for processing.
This form is for non-participating providers seeking claims with EmblemHealth. All participating network providers must submit claims forms directly to EmblemHealth for processing.
PDF
Prism Chiropractic Treatment Form (PPO)
For chiropractic services that require pre-certification, fax this treatment form to 716-712-2817 or call Prism at 1-866-284-2901.
For chiropractic services that require pre-certification, fax this treatment form to 716-712-2817 or call Prism at 1-866-284-2901.
PDF
Dental Claim Form
This form allows you to submit a dental claim having visited a non-participating dentist. All participating network dentists must submit claims forms directly to GHI for processing.
This form allows you to submit a dental claim having visited a non-participating dentist. All participating network dentists must submit claims forms directly to GHI for processing.
PDF
Prescription Drug Forms
Please check your ID card. If you have an Express Scripts logo on the front of your ID card, please use the Express Scripts, Inc. prescription drug claim form below. If you see GHI Pharmacy Services on the back of your ID card, please use the GHI Pharmacy Services prescription drug claim form below.
| Pharmacy Managed by
Express Scripts | Pharmacy Managed by
GHI or GHI HMO Pharmacy Services |
Express Scripts Forms | 
GHI or GHI HMO Pharmacy Services Forms |
GHI HMO Forms
Name/Description
Format
Coordination of Benefits Questionnaire (HMO)
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. (1 page)
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. (1 page)
PDF
Student Verification Parent Affidavit 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
GHI HMO Pharmacy Services prescription drug claim form
This form allows you to submit claims for GHI HMO prescriptions. All claims must be filed with the following information: the name of the patient, the strength and quantity of each drug, the prescription number of each drug, the name and address of the pharmacy; the name of the prescribing physician and prescription receipts. (2 pages)
This form allows you to submit claims for GHI HMO prescriptions. All claims must be filed with the following information: the name of the patient, the strength and quantity of each drug, the prescription number of each drug, the name and address of the pharmacy; the name of the prescribing physician and prescription receipts. (2 pages)
PDF
Medical Claim Form (HCFA-1500 form)
This form is for non-participating providers seeking claims with EmblemHealth. All participating network providers must submit claims forms directly to EmblemHealth for processing.
This form is for non-participating providers seeking claims with EmblemHealth. All participating network providers must submit claims forms directly to EmblemHealth for processing.
PDF
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)
See also: Prior authorization requirements - quick reference guide.
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)
See also: Prior authorization requirements - quick reference guide.
PDF
Prism Treatment Plan Forms (HMO)
All chiropractic care* and physical and occupational therapy services require a referral from the Primary Care Physician. The PCP should fax a copy of the referral form to Prism at 716-712-2817. After the initial visit, providers must contact Prism for additional visits by submitting this treatment plan form for review and consideration. Providers are also required to report their findings and treatments to the member's PCP.
- Chiropractic Treatment Form
- Physical and Occupational Therapy Treatment Form
*except HMO Direct Access
All chiropractic care* and physical and occupational therapy services require a referral from the Primary Care Physician. The PCP should fax a copy of the referral form to Prism at 716-712-2817. After the initial visit, providers must contact Prism for additional visits by submitting this treatment plan form for review and consideration. Providers are also required to report their findings and treatments to the member's PCP.
- Chiropractic Treatment Form
- Physical and Occupational Therapy Treatment Form
*except HMO Direct Access
PDF
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
Referral Form Sample (HMO)
The GHI HMO Specialty Referral Process enables Primary Care Physician (PCP) to coordinate the process by which their patients receive care from specialists. Primary Care Physicians (PCPs) who identify a need for a referral will simply give a referral number to the participating specialist. The PCP does not need to submit a copy of the referral form to GHI HMO. Assigned referrals will be valid for a period of one year from the initial date of service. Click here for complete instructions. (1 page)
Effective, January 1, 2004, you will no longer receive a confirming letter from GHI HMO for referrals issued by the Primary Care Physician.
The GHI HMO Specialty Referral Process enables Primary Care Physician (PCP) to coordinate the process by which their patients receive care from specialists. Primary Care Physicians (PCPs) who identify a need for a referral will simply give a referral number to the participating specialist. The PCP does not need to submit a copy of the referral form to GHI HMO. Assigned referrals will be valid for a period of one year from the initial date of service. Click here for complete instructions. (1 page)
PDF
Miscellaneous Forms
Name/Description
Format
Coordination of Medicare Benefits
The health insurance program you chose provides that if you are a member of an employer group of less than 20 employees and are eligible for Medicare (due to age), Medicare is primary and GHI would be secondary. Please return this completed form to GHI so that we can continue to keep our records current. (1 page)
The health insurance program you chose provides that if you are a member of an employer group of less than 20 employees and are eligible for Medicare (due to age), Medicare is primary and GHI would be secondary. Please return this completed form to GHI so that we can continue to keep our records current. (1 page)
PDF
Medicare Supplement Insurance Application
If you are currently eligible for Medicare and are interested in obtaining a Medicare Supplemental plan from GHI please complete this form and return it to GHI. Your coverage will be effective on the first day of the following month it is received. (2 pages)
If you are currently eligible for Medicare and are interested in obtaining a Medicare Supplemental plan from GHI please complete this form and return it to GHI. Your coverage will be effective on the first day of the following month it is received. (2 pages)
PDF
