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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 Quick Guides

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General Forms
 
Advance Patient Notification Form  
 
COB Questionnaire  
 
Individual Provider Tax ID Update Form 
 
Individual Provider Billing Address Update Form 
 
Individual Provider Record Update Form 
 
Specialist Patient Coverage Waiver  
 
EDI Registration Form  
 
Physician Online Services Account Unlock Form  
 
General Fax Authorization 
 
Managed Care Referral 
 
Primary Care Physician (PCP) Patient Coverage Waiver 
 
Notice of Denial of Medical Coverage 
 
Obstetrical Fax Authorization 
 
Empire’s National Provider Identification (NPI) Registration Form 
 
Refund Check Information Form 
 
Plan B PAB Fax Form  
 
 

Pre-Determination Forms
 
ESA Pre-Determination Request Form  
 
Avastin® (bevacizumab)  
 
Erbitux® (cetuximab)  
 
Herceptin® (trastuzumab)  
 
Prialt® (ziconotide) Intrathecal Infusion  
 
Rocephin® (ceftriaxone) for Lyme Disease 
 
Vectibix™ (panitumumab) 
 
Vivitrol® (naltrexone injection) 
 
 
 

Prior Authorization Forms
 
5-Alpha-Reductase Inhibitors 
 
Actiq  
 
Activella  
 
Adcirca 
 
Aldara 
 
Alora 
 
Ambien CR 
 
Amevive 
 
Anadrol 
 
Androgens 
 
Android  
 
Androxy 
 
Antifungal Oral Therapy 
 
Aranesp 
 
Arixtra  
 
Atrovent 
 
Augmentin 
 
Avastin  
 
Avonex  
 
Aygestin 
 
Azelex 
 
Betaseron  
 
Botulinum Toxin 
 
Brand NSA  
 
Bravelle 
 
Bronchodilators  
 
Cardura XL 
 
Caverject 
 
Ceftin Long Term Use 
 
Cenestin 
 
Cetrotide 
 
Cialis 
 
Cimzia  
 
Cipro 
 
Ciprofloxacin  
 
Climara and Climara Pro 
 
Clomiphene Citrate 
 
Colony Stimulating Factors  
 
CombiPatch  
 
Combivent 
 
Copaxone  
 
Crinone 
 
Divegel  
 
Edex 
 
Elestrin  
 
Elidel and Protopic  
 
Eligard 
 
Enbrel 
 
Endometrin 
 
Erbitux 
 
Erectile Dysfunction  
 
y 
 
Estraderm  
 
Evamist  
 
FemHRT  
 
Fentora  
 
Flolan 
 
Flomax  
 
Follistim AQ 
 
Forteo  
 
Ganirelix 
 
Gleevec 
 
GnRH Analogs 
 
Gonal-F 
 
Gonal-F RFF 
 
Hepatitis 
 
Herceptin  
 
HP Acthar  
 
Human Growth Hormone  
 
Humira  
 
Immune Globulin 
 
Increlex 
 
Infergen 
 
Infertility Medications 
 
Isotretinoin  
 
Kineret 
 
Leukine 
 
Levaquin 
 
Levitra 
 
Low Molecular Weight Haparins  
 
Lucentis 
 
Lupron 
 
Lupron Depot 
 
Lupron Depot Ped 
 
Luveris 
 
Lyrica  
 
Macugen 
 
Menest 
 
Menopur 
 
Migranal Nasal Spray 
 
Muse 
 
Nasal Corticosteroid  
 
Neulasta 
 
Neumega 
 
Neupogen 
 
Nexavar 
 
Non Preferred benzoyl peroxide-clindamycin  
 
Noroxin  
 
Nor-QD 
 
Novarel 
 
Nuvigil  
 
Ofloxacin 
 
Ogen 
 
Orencia 
 
Ortho Micronor  
 
Ortho-EST 
 
Ovidrel 
 
Oxandrin 
 
Pegylated Interferons 
 
Penlac 
 
Pregnyl 
 
Primaxin 
 
Prochieve 
 
Procrit and Epogen 
 
Promethazine 
 
Prometrium 
 
Prostacyclins 
 
Proton Pump Inhibitors (PPI) 
 
Provera 
 
Provigil 
 
Qualaquin  
 
Quantity Limitation Override Request Form 
 
Raptiva 
 
Rebif  
 
Remicade 
 
Remodulin 
 
Repronex 
 
Revlimid 
 
Rituxan 
 
Rocephin 
 
Roferon-A/Intron-A 
 
Savella 
 
Sildenafil  
 
Spiriva 
 
Sprycel 
 
Subutex  
 
Supprelin 
 
Sutent 
 
Synagis 
 
Synarel 
 
Tadalafil  
 
Tarceva 
 
Targretin 
 
Tasigna 
 
Testred  
 
Thalomid 
 
Topamax 
 
Toradol 
 
Trelstart Depot or LA 
 
Tykerb 
 
Tysabri 
 
Vantas 
 
Vectibix 
 
Vfend 
 
Viadur 
 
Vivelle 
 
Vivitrol 
 
Vytorin 
 
Xeloda 
 
Xolair 
 
Zoladex 
 
Zolinza 
 
Zyvox 
 
 

Behavioral Health
 
Outpatient Treatment Report  
 
Individual Authorization Form  
 
Provider Maintenance Form  
 
Provider Specialty Profile  
 
Psychological Testing Authorization Form  
 
Psychotherapy Notes Authorization Form  
 
 

Quick Guides
 
Empire Fastcheck IVR Guide for Medical Providers 
 
Empire Fastcheck IVR Guide for Hospital Providers 
 
Institutional Quick Guide 
 
Professional Quick Guide 
 

The documents on this page are available in Adobe Acrobat format. Adobe Acrobat can be downloaded here.

 
©2009 Empire BlueCross BlueShield

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.