Please log-in to myEmblemHealth and you will be able to print the 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 EmblemHealth for processing.
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.