Forms and Documents

Use this form if you are a plan member or the child of a plan member who is now a young adult and wants to be covered under your parent's plan. Members who have an On Exchange plan must contact NYSOH at 1‑855‑355‑5777 to elect coverage under the Young Adult rider.

Use this form if you are a plan member or the child of a plan member who is now a young adult and wants to be covered under your parent's plan.

If your dependent is a student, use this form to prove enrollment in a higher education school.

If your dependent is a student, use this form to prove enrollment in a higher education school.

Use this form to maintain coverage for your dependent who has not married, is disabled, and became disabled before reaching the age at which dependent coverage would otherwise end. NYSHIP members must obtain the Statement of Disability form (PS-451) from their health benefits administrator.

When members are changing their primary care physicians (PCPs) from different medical centers or private physician offices, this form should be used.

This form assists you in the coordination of benefits received under more than one health insurance program by you or any dependent.

This form assists you in the coordination of benefits received under more than one health insurance program by you or any dependent.

This form assists you in the coordination of benefits received under more than one health insurance program by you or any dependent.

If your benefit plan includes the ExerciseRewardsTM Program, use this form to verify you are a member at a fitness facility.

With the ExerciseRewardsTM program, you can enjoy the benefits of exercise and get paid back for your dues.

If your benefit plan includes the ExerciseRewardsTM Program, use this form to get back up to $200 of your membership dues.

Use this form to submit dental claims to EmblemHealth

2021 Bronze Summary of Benefits and Coverage

2021 Bronze Subscriber Contract

2021 Essential Plan 1 Benefit Summary

2021 Essential Plan 1 Summary of Benefits and Coverage

2021 Essential Plan 1 Plus Benefit Summary 

2021 Essential Plan 1 Plus Summary of Benefits and Coverage

2021 Essential Plan 1 and 2 Native American Benefit Summary

2021 Essential Plan 1 and 2 Plus Native American Benefit Summary

2021 Essential Plan 2 Benefit Summary

2021 Essential Plan 2 Summary of Benefits and Coverage

2021 Essential Plan 2 Plus Benefit Summary

2021 Essential Plan 2 Plus Summary of Benefits and Coverage

2021 Essential Plan 3 Benefit Summary

2021 Essential Plan 3 Summary of Benefits and Coverage

2021 Essential Plan 4 Benefit Summary

2021 Essential Plan 4 Summary of Benefits and Coverage

2021 Gold Benefit Summary

2021 Gold Summary of Benefits and Coverage

2021 Gold Subscriber Contract

2021 Gold Value Benefit Summary

2021 Gold Value Summary of Benefits and Coverage

2021 Gold Value Subscriber Contract

2021 Platinum Benefit Summary

2021 Platinum Summary of Benefits and Coverage

2021 Platinum Subscriber Contract

2021 Silver Benefit Summary

2021 Silver Summary of Benefits and Coverage

2021 Silver Subscriber Contract

2021 Silver Bold Benefit Summary

2021 Silver Bold Summary of Benefits and Coverage

2021 Silver Bold Subscriber Contract

2021 Bold CSR 1, Bold CSR 2, Bold CSR 3 Benefit Summary

2021 Bold CSR 1, Bold CSR 2, Bold CSR 3 Summary of Benefits and Coverage

2021 Bold CSR 1, Bold CSR 2, Bold CSR 3 Subscriber Contract

2021 Silver CSR 1, CSR 2, CSR 3 Benefit Summary

2021 Silver CSR 1, CSR 2, CSR 3 Summary of Benefits and Coverage

2021 Silver CSR 1, CSR 2, CSR 3 Subscriber Contract

2021 Silver Value Benefit Summary

2021 Silver Value Summary of Benefits and Coverage

2021 Silver Value Subscriber Contract

2021 Silver Value CSR 1, CSR 2, CSR 3 Benefit Summary

2021 Silver Value CSR 1, CSR 2, CSR 3 Summary of Benefits and Coverage

2021 Silver Value CSR 1, CSR 2, CSR 3 Subscriber Contract

2021 Standard Native American/Alaskan Native

2021 Non-Standard Native American/Alaskan Native

2021 Silver Bold Non-Standard Native American/Alaskan Native

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract

Benefit Summary
Summary of Benefits and Coverage (SBC)

Benefit Summary
Summary of Benefits and Coverage (SBC)

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract

Benefit Summary
Summary of Benefits and Coverage (SBC)

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract

Benefit Summary
Summary of Benefits and Coverage (SBC)
Subscriber Contract