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).
Authorization for Release of Information
Use when an Empire subscriber or plan member wishes to designate a representative to interact (inquire) with Empire on his or her behalf.
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.
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.
Student Coverage Questionnaire
Use this form to prove your child, over the age of 19, is enrolled in a higher education school.
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.
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).
Dental
Dental Claim Form
If you receive services from a non-participating dentist, use this form.
Vision
Vision Claim Form
If you receive services from a non-participating vision provider, use this form.
Pharmacy
Prescription Drug Claim Form
If you have prescription drug coverage through your Empire plan and you use a non-participating pharmacy, use this form to report the services that you or a member of your family received.
Prescription Drug Mail-Order Form
If you have prescription drug coverage through your Empire plan that includes a mail-order benefit, use this form to enroll.
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.
MediBlue Plus Prescription Drug Mail-Order Form
Your prescription drug coverage through MediBlue HMO includes a mail-order benefit. Use this form to order new and/or refill mail service prescriptions.
MediBlue PPO Plus Prescription Drug Mail-Order Form
Your prescription drug coverage through MediBlue PPO Plus includes a mail-order benefit. Use this form to order new and/or refill mail service prescriptions.
MediBlue Plus Prescription Drug Mail-Order Form
Your prescription drug coverage through MediBlue HMO includes a mail-order benefit. Use this form to order new and/or refill mail service prescriptions if you reside in Albany, Rennselaer, Saratoga and Schenectady Counties.
The documents on this page are available in Adobe Acrobat format. Adobe Acrobat can be downloaded here.
