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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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Empire Dental Prime and Complete Member Services

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Member Services 
Empire Dental Prime and Complete Member Services
 
Member Forms 
Click on the icons in the "Upstate" column if you are located in one of the following counties: Albany, Clinton, Essex, Fulton, Montgomery, Rensselear, Saratoga, Schenectady, Schoharie, Washington and Warren. For members located in all other counties choose "Downstate”. 

  Downstate
Upstate

Dental Claim Form

PDF Format

Authorization to Release Information

PDF Format

PDF Format

Authorization to Release Information - Spanish

PDF Format

PDF Format

International Emergency Dental Program Flyer

PDF Format

PDF Format

International Emergency Dental Program Frequently Asked Questions

PDF Format

PDF Format

Disabled Dependent/Michelle’s Law Application

PDF Format

Extra cleaning sign up form for diabetic and pregnant members

PDF Format

Dental Provider Nomination Form 

PDF Format

     
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(877) 606-3338 
 
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Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans, serving residents and businesses in the 28 eastern and southeastern counties of New York State. All external sites will open in a new browser window. Please view our Website Privacy Policy for more information.