Forms
PW_AD067467
Below are forms that you may need in order to do business with Empire.
The documents on this page are available in either Adobe Acrobat or Word Format. Click on the icon to download forms. Forms in Word format can be edited after clicking the Word icon, click "save" to download the file to your desktop.
Insurance Producer Agreement
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Anthem Life & Disability Insurance Company (Anthem Life)*
Use these forms to become appointed with Anthem Life.
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Producer Agreement
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Personal Datasheet
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To receive compensation for life and disability business you must be contracted with Anthem Life & Disability Insurance Company, which is a NewYork-specific company.
Fax completed contract, personal datasheet, W9 with copy of producer, corporate license if applicable, and proof of errors coverage to Anthem Life, Attn: Melinda Chavis, 1-317-287- 8721.
Or, mail the above information to:
Anthem Life
Attn: Melinda Chavis, Licensing & Credentialing
P.O. Box 6087
Indianapolis, IN46206
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NY HIPAA Business Associate Agreement
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Request for Forms
*Use this form for ordering any of following forms: Member PCP Change, Member Name Change, Member Address Change, Member Info Request, Group Contact Rep Change, Group Billing Info Update, Group Info Request and/or Termination and Reinstatement.
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Broker of Record Letter Template and Instructions
Groups should complete the form on their own company's letterhead and fax the request to 1-718-312-6052, or mail it to: Empire BlueCross BlueShield, Attn: Broker Commissions, 15 Metrotech Center, 6th Floor, Brooklyn, NY 11201
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W-9 Tax Form
Please complete and return the W-9 tax form. It can be faxed to 1-518-367-5194 or mailed to: Empire Accounts Payable, PO Box 11811, Mailing Drop J5, Albany, NY 12211-0811.
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Mellon Health Savings Account (HSA) Agreement
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Mellon HSA Employer Funding Guide
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Forms to send to your clients
Click on the icons in the "Upstate" column in the following New York counties: Albany, Clinton, Essex, Fulton, Montgomery, Rensselear, Saratoga, Schenectady, Schoharie, Washington and Warren. For clients located in all other counties choose "Downstate."
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Region
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COBRA Model Notices
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Downstate
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Upstate
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Model COBRA Continuation Coverage Election Notice
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Model General Notice of COBRA Continutation Coverage Rights
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Region
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Small Group Forms
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Downstate
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Upstate
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Authorization for Electronic Check/ACH via Telephone Request
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General Notice of Pre-existing Conditions -- HIPAA Requirement
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Small Group Application/Change Form
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Small Group Renewal Worksheet
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Small Group Health Benefits Waiver
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Small Group New York Recredentialing Form
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Domestic Partner Rider for Small (2-50 Employees) HMO Plans
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Small Group Healthy NY Application
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Healthy NY Group Contract
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Healthy NY Annual Re-certification
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Region
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Large Group Forms
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Downstate
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Upstate
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Large Group Application/Change Form
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Anthem Life & Disability Insurance Company (Anthem Life)* Forms
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Employer Disability Application
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Employee Disability Application; used for guarantee issue benefits
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Employee Disability Application with medical questionnaire; used for benefits greater than guarantee issue
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Employer Life Application
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Employee Life Application; used for guarantee issue benefits
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Employee Life Application with medical questionnaire; used for benefits great than guarantee issue
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Hold Harmless Form
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Evidence of Insurability
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Region
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Vision
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Downstate
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Upstate
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Vision Out-of-Network Claim Forms
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Region
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Other Forms
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Downstate
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Upstate
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Subrogation Rider for Groups with HMO plans
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Subrogation Rider for Groups with all other plans
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Employer Online Services Delegation Form
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Group Contract For HMO or Direct HMO
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Handicapped/Dependent Form (HAC 506)
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Member Enrollment/Change Form
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Member Enrollment/Change Form (Spanish Version)
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Student Coverage Questionnaire
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