Forms

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The documents on this page are available in either Adobe PDF 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. 
Use 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".  

Plan administration forms
Downstate
Upstate
Stop Loss Policy Application  

2019 NY SG Change Form - Medical, Dental, Vision (effective 1/1/2019) 

2019 NY SG Employer Application - Medical, Dental, Vision (effective 1/1/2019) 

2019 NY SG Employee Application - Medical, Dental, Vision (effective 1/1/2019) 

2019 NY SG Change Form - Medical, Dental, Vision (effective 1/1/2019) SPANISH 

2019 NY SG Employee Application - Medical, Dental, Vision (effective 1/1/2019) SPANISH 

2019 NY SG Attestation Form (effective 1/1/2019) 

2019 NY Demographic Change Application (effective 1/1/2019) 

2019 Healthy Employer Application (effective 1/1/2019) 

2019 Healthy Recertification Application (effective 1/1/2019)  

2017 Small Group NY Employer Benefit Plan Change Form – Printable  

2017 Small Group NY Employer Benefit Plan Change Form – Fillable  

2017 Small Group Healthy New York Employer Enrollment Application – Printable  

2017 Small Group Healthy New York Employer Enrollment Application – Fillable  

2017 Small Group Healthy New York Coverage Waiver – Printable  

2017 Small Group Healthy New York Coverage Waiver – Fillable  

2017 Small Group NY Employee Application – Printable  

2017 Small Group NY Employee Application – Fillable  

2017 Small Group NY Employer Application – Printable  

2017 Small Group NY Employer Application – Fillable  

2017 Small Group NY Employee Change Application – Printable  

2017 Small Group NY Employee Change Application – Fillable  

2017 Small Group Healthy New York Annual Re-certification Form – Printable  

2017 Small Group Healthy New York Annual Re-certification Form – Fillable  

NY Empire 2017 Attestation Form  

Healthy NY Supplemental Employer Form For 1–50 Employee Small Group  

Healthy NY Employer Enrollment Application For 1–50 Employee Small Group  

Healthy NY Employer Enrollment Application For 1–50 Employee Small Group [effective 1/1/16]  

Healthy New York Coverage Waiver For Groups of 1–50  

Healthy New York Coverage Waiver For Groups of 1–50 [effective 1/1/16]  

Healthy New York Annual Re-certification Form For Groups of 1–50  

Healthy New York Annual Re-certification Form For Groups of 1–50 [effective 1/1/16]  

Healthy New York Annual Re-certification Form For Groups of 1–50 – Spanish  

Small Group EmployerAccess Usage Agreement  

Off-Exchange EMPLOYEE Change Form: 1–50 Employee Small Groups  

Off-Exchange EMPLOYEE Change Form: 1–100 Employee Small Groups [effective 1/1/16]  

Off-Exchange EMPLOYEE Change Form: 1–50 Employee Small Groups – Spanish  

Off-Exchange EMPLOYEE Enrollment Application: 1–50 Employee Small Groups [effective 1/1/15]  

Off-Exchange EMPLOYEE Enrollment Application including Dental Prime and Complete: 1–50 Employee Small Groups [effective 10/1/15] 

Off-Exchange EMPLOYEE Enrollment Application: 1–100 Employee Small Groups Medical Only [effective 1/1/16]  

Off-Exchange EMPLOYEE Enrollment Application: 1–100 Employee Small Groups Medical/Dental/Vision [effective 1/1/16]  

Off-Exchange EMPLOYEE Enrollment Application: 1–50 Employee Small Groups - Spanish [effective 1/1/15]  

Off-Exchange EMPLOYEE Enrollment Application: 1–100 Employee Small Groups Medical/Dental/Vision - Spanish [effective 1/1/16] 

Off-Exchange EMPLOYER Enrollment Application: 1–50 Employee Small Groups [effective 1/1/15]  

Off-Exchange EMPLOYER Enrollment Application including Dental Prime and Complete: 1–50 Employee Small Groups [effective 10/1/15] 

Off-Exchange EMPLOYER Enrollment Application: 1–100 Employee Small Groups Medical Only [effective 1/1/16]  

Off-Exchange EMPLOYER Enrollment Application: 1–100 Employee Small Groups Medical/Dental/Vision [effective 1/1/16]  

Off-Exchange EMPLOYER Benefit Plan Change Form: 1–50 Employee Small Groups  

Off-Exchange EMPLOYER Benefit Plan Change Form: 1–100 Employee Small Groups [effective 1/1/16]  

Off-Exchange EMPLOYER Benefit Plan Change Form: 1–50 Employee Small Groups – Spanish  

Group Health Plan Request for SSN Form  

Small Group Application Change Form (2-50 eligible employees)  

Large Group Application Change Form (101+ eligible employees)  

Small Group Health Benefits Waiver Form  

Member Enrollment/Change Form  

Member Enrollment/Change Form – Spanish  

Handicapped/Dependant Form (HAC 506)  

Student Coverage Questionnaire Form  

Group Contract For HMO or Direct HMO  

Electronic Check/ACH (Telephone) Authorization  

ASO Business Associate Agreement  

 

Working with your Broker
Downstate
Upstate
Employer Online Services Delegation Form 

Broker of Record Letter 

 

For your employees:
Notices

Downstate
Upstate
General Notice of Pre-existing Conditions -- HIPAA Requirement  

Privacy Policy  

Employee Cancer Benefits  

Sample Premium Contribution Increase Notification Letter  

Sample E-mail to Employees about Online Wellness Tools  

 

Riders
Downstate
Upstate
Infertility Riders for Groups with HMO plans  

Infertility Riders for Groups with all other plans  

Subrogation Rider for Groups with HMO plans  

Subrogation Rider for Groups with all other plans  

Domestic Partner Rider for Small (2-50 Employees) HMO Plans  

 
 

Dental Forms
Downstate
Upstate
Empire Dental Essential and Consumer Choice Membership Enrollment Form 

Empire Dental Essential and Consumer Choice Membership Maintenance Form 

Empire Whole Health Connection – Dental Self Enrollment Form (Dental Essential & Consumer Choice)  

 
 

Vision
Downstate
Upstate
Vision Out-of-Network Claim Form  

 

Medicare
Downstate 
Upstate 
Creditable Coverage Guidance  

Medicare Eligibility  

 

COBRA Model Notices
Downstate
Upstate
Model COBRA Continuation Coverage Election Notice  

Model General Notice of COBRA Continuation Coverage Rights  

©2018 Empire BlueCross BlueShield

Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., and/or HealthPlus, LLC., 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.