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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 and Documents

PW_AD067471

General
 
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American Specialty Health – Chiropractic Claim Form
If you see a chiropractor who is out-of-network, as of March 1, 2012, claims must be submitted to American Specialty Health Networks (and not to Empire) either by you or by your out-of-network provider. If you receive services from a non participating chiropractic provider, please use this claim form. 
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FSA Enrollment Form - Downstate
Complete this Flexible Spending Account Enrollment form and submit to your human resources representative. 
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FSA Enrollment Form - Upstate
Complete this Flexible Spending Account Enrollment form and submit to your human resources representative 
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Notice of Election Form (HMO Members Only)
Use when certain enrollment changes must be submitted in writing (i.e., request that a member be terminated from a plan, add a baby to a plan). 
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Request for coverage for an over-age dependent
If your over-age dependent child is mentally challenged or physically handicapped, he or she may be eligible for coverage. Use this form to verify that specific enrollment criteria are met. 
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MEMBER SUBMITTED - Health Insurance Claim Form*
If you see a non-participating physician and have out-of-network benefits, use this form to report the services that you or a covered member received. 
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Student Coverage Questionnaire
Use this form to prove your child, over the age of 19, is enrolled in a higher education school. 
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Coordination of Benefits (COB) Form
When a member is covered by two healthcare plans, the benefits from both plans need to be coordinated in order to prevent duplication. Requests for benefits should be submitted first to your primary plan. Any portion not covered by the primary plan can then be submitted to your secondary plan for consideration of payment. 
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Medicare Supplement — Third Party Designation
If you are a Medicare Supplement member, use this form to designate an individual to receive a reminder notice that your Empire premium payment is past due. (The reminder will be sent on the actual date the premium is due indicating Empire has not received it yet).  
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Dental
 
Dental Claim Form
If you receive services from a non-participating dentist, use this form. 
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Empire Dental Prime and Complete Forms
If you are a member of our Empire Dental Prime or Complete plans, please use these forms. 
 
   
Vision
 
Vision Claim Form
If you receive services from a non-participating vision provider, use this form. 
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Pharmacy Forms
 
Home Delivery Pharmacy Order Form
Prescription Drug Claim Form

If you have prescription drug coverage through your Empire plan that includes a mail-order benefit, use the Home Delivery Pharmacy Order Form to enroll. If you have prescription drug coverage through your Empire plan, and you use a non-participating pharmacy, use the Prescription Drug Claim Form to report the services that you or a member of your family received. 
To find these forms, members must visit the Express Scripts website after login to their health plan site. After login, select “access your pharmacy benefits” from the Pharmacy page. On the Express Scripts site, select the forms from the Printable Forms section.  
 
   
   
MediBlueSM Forms
 
MediBlue Prescription Drug Claim Form
If you have prescription drug coverage through MediBlue and you use a non-participating pharmacy, use this form to report the services that you received. 
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MediBlue Plus Prescription Drug Home Delivery Form
Your prescription drug coverage through MediBlue HMO includes a home delivery benefit. Use this form to order new and/or refill home delivery prescriptions. 
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MediBlue PPO Plus Prescription Drug Home Delivery Form
Your prescription drug coverage through MediBlue PPO Plus includes a home delivery benefit. Use this form to order new and/or refill home delivery prescriptions. 
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MediBlue Plus Prescription Drug Home Delivery Form
Your prescription drug coverage through MediBlue HMO includes a home delivery benefit. Use this form to order new and/or refill home delivery prescriptions if you reside in Albany, Rennselaer, Saratoga and Schenectady Counties. 
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