Health Insurance Forms
| Empire Plan Waiver of Premium | For members on LWOP who are enrolled in the Empire Plan only and wish to apply for a waiver of premium |
| Empire Plan/United HealthCare Predetermination Request | For members who wish to submit a predetermination of benefits to United HealthCare concerning a particular procedure to verify coverage |
| Empire Plan/United HealthCare Claim Form | To submit claims to United HealthCare received by an out-of-network providerEmpire Plan Coordination of Benefits (COB) Forms |
| United HealthCare | Notify United HealthCare that dependent has other insurance |
| BlueCross/BlueShield | Notify Empire BlueCross/BlueShield that dependent has other insurance |
| Empire Plan Dependent Student Verification Form | |
| United HealthCare | Notify United HealthCare of dependent’s age (19-25) full-time college status (must submit each semester) |
| BlueCross/BlueSheild | Notify BlueCross/BlueShield of dependent’s (age 19-25) full-time college status (must submit each semester) |
| GHI Dependent Student Certification Form | Notify GHI of dependent’s (age 19-25) full-time college status (must submit each semester) |
| EyeMed Student Verification Form | Notify EyeMed of dependent’s (age 19-25) full-time college status (must submit each semester) |
