Forms for Employees of NYSHIP Participating Agencies (PA) Enrolled in the Empire Plan

NYSHIP Claims and Administrative Forms

Please see the forms below for mailing addresses, fax numbers and specific instructions on how to submit claims.

Hospital Program

Anthem Blue Cross Claims Form

Medical/Surgical Program

Empire Plan Health Insurance Claim Form

Prescription Drug Program

Mental Health and Substance Use Program

Mental Health and Substance Use Claim Form

Health, Dental and Vision Forms

PS 425 Domestic Partner Series

PS 451 (9/2020 L) NYSHIP Statement of Disability for Dependents

PS 452 (10/2020 L) Application for Waiver of Empire Plan Premium

PS 457 (3/2025) NYSHIP Statement of Dependence for "Other" Children

PS 503 (1/2025) NYSHIP Health Insurance Transaction Form for Participating Agencies (PAs)

HIPAA Authorization Form

EBD-543 (2/23) Authorization for Release of Protected Health Information

For additional forms, contact your Agency Health Benefits Administrator.