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  • Emblemhealth Student Verification Form

Get Emblemhealth Student Verification Form

STUDENT VERIFICATION PARENT AFFIDAVIT FORM Mail form to: Membership, PO Box 2821, New York, NY 10116-2821 TO BE COMPLETED BY THE SUBSCRIBER Employer Name Subscriber Name Subscriber ID # Student Name.

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How to use or fill out the Emblemhealth Student Verification Form online

Filling out the Emblemhealth Student Verification Form online is a straightforward process that ensures your dependent's eligibility for health coverage. This guide will walk you through each section of the form, providing clear and supportive instructions.

Follow the steps to accurately complete the form online:

  1. Click ‘Get Form’ button to obtain the form and access it in your preferred online editor.
  2. Enter the employer name in the designated field to identify the subscriber.
  3. Provide the subscriber's name and Subscriber ID number to ensure proper identification.
  4. Fill in the student's name as registered in the educational institution.
  5. Input the name of the school the student attends.
  6. Complete the school address fields, including city, state, and ZIP code for accurate communication.
  7. Include the school phone number to allow Emblemhealth to verify information if necessary.
  8. Certify the dependent student’s eligibility by selecting 'Yes' or 'No' for the stated criteria: age, marital status, and financial support.
  9. State the expected date of graduation and select full-time or part-time status.
  10. Confirm enrollment in an accredited institution by providing the semester's start and end dates.
  11. Review the information provided to ensure accuracy before signing.
  12. Sign and date the form in the appropriate section to confirm the truthfulness of the information.
  13. Once the form is completed, options will be available to save changes, download, print, or share the document as needed.

Ensure you complete the Emblemhealth Student Verification Form online accurately and promptly.

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Contact support

To access an interpreter, providers may call 866-447-9717 and a Provider Customer Care Advocate will assist you. Providers, members, or their designee can contact the Customer Service Department via phone at 646-447-6534 or TTY/TDD at 800-874-9426 to request a sign language interpreter for a provider appointment.

Quick Links. Customer Service: 877-244-4466, seven days a week (excluding major holidays), 8 am to 8 pm.

Call Us. You can also use our automated phone system for network providers. Call 1-212-501-4444 (in NYC) or 1-800-624-2414 (outside NYC).

Merger of GHI and HIP On September 29, 2005, the boards of directors of GHI and HIP announced an agreement to merge the two companies. The resulting company, to be named EmblemHealth, would be governed by a Foundation made up of an equal number of directors from both companies.

EmblemHealth ID cards will display the full 11 digits. Empire BCBS will adopt the same K-ID but will only use and display the first 9 digits on their member ID cards.

Large Group Plan Features A range of options so you can find the right plan for you and your employees. In-network primary and specialty care at 30+ locations in NYC and Long Island. Education, support, and discounts to help keep your employees healthy.

EmblemHealth's family of companies includes ConnectiCare, one of Connecticut's leading health plans; AdvantageCare Physicians, a primary and specialty care practice; and WellSpark, a digital wellness company.

Quick Start Guide To Your Benefits You're a member of the EmblemHealth PPO plan that uses the National network.

Two companies from those early days of health insurance, Group Health Incorporated (GHI) and Health Insurance Plan of Greater New York (HIP), would later merge and become EmblemHealth. And after 80 years, our mission is still the same: to create healthier futures for our customers and communities.

Customer Service: 877-244-4466, seven days a week (excluding major holidays), 8 am to 8 pm.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232