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Print New ID Cards. Search Claims. And a whole lot more.
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Find a Doctor
Find a doctor or hospital locally or across the country.
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What is Empire's 360° Health® program?
A total health solution that helps members become more healthy, or live better with a condition, while lowering the cost of health care.
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Forms
PW_AD067515
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.
Click on the icons in the "Upstate" column if you are located in one of the following New York counties: Albany, Clinton, Essex, Fulton, Montgomery, Rensselear, Saratoga, Schenectady, Schoharie, Washington and Warren. For employers located in all other counties choose "Downstate."
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Region
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Plan administration forms
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Downstate
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Upstate
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Small Group Application Change Form (2-50 eligible employees)
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Large Group Application Change Form (51+ eligible employees)
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Small Group Health Benefits Waiver Form
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Member Enrollment/Change Form
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Member Enrollment/Change Form (Spanish Version)
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Handicapped/Dependant Form (HAC 506)
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Student Coverage Questionnaire Form
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Group Contract For HMO or Direct HMO
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Small Group New York Recredentialing Form
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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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Electronic Check/ACH (Telephone) Authorization
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Working with your Broker
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Region
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Downstate
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Upstate
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Employer Online Services Delegation Form
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Broker of Record Letter
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For your employees
Notices
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Region
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Downstate
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Upstate
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General Notice of Pre-existing Conditions -- HIPAA Requirement
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Privacy Policy
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Employee Cancer Benefits
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Sample Premium Contribution Increase Notification Letter
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Sample E-mail to Employees about Online Wellness Tools
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Riders
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Region
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Downstate
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Upstate
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Infertility Riders for Groups with HMO plans
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Infertility Riders for Groups with all other plans
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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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Domestic Partner Rider for Small (2-50 Employees) HMO Plans
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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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Medicare
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Region
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Downstate
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Upstate
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Creditable Coverage Guidance
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Medicare Eligibility
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COBRA Model Notices
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Region
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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 Continuation Coverage Rights
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