Insurance Company:

Empire BC/BS

Empire Medicare (National Government Services)

New York State Medicaid

HIP Health Plan of New York

GHI Medicare (Queens County - National Government Services)

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Empire Blue Cross Blue Shield Enrollment Form

Please mail the form to the following address:

   EMC Marketing
   800 Second Avenue
   3rd Floor
   New York, NY 10017

Please make sure that our submitter ID 014947 can be recognized on paper.

To check if the provider id is ready to submit with our submitter id please call 1(800)992-2583

Empire Blue Cross Blue Shield Enrollment Package

Click to Download Blue Cross Blue Shield form

Empire Medicare (NGS) Enrollment Forms

Please fax the form to the following fax number:

   315-442-4414

Please make sure that our submitter ID CH0000549 can be recognized on the form

To check if the provider ID is ready to submit with our submitter ID please call 877-273-4334

Empire Medicare (NGS) Enrollment Form

Click to Download Empire Medicare form

Medicaid Enrollment Form

please have it NOTARIZED and mail it to the following address:

Provider Setup
CSC
1 CSC Way
Rensselaer, NY 12144

To check if the provider id is read to submit with our submitter id please call

(518) 447-9256

Please make sure that our TSN:05D can be recognized on paper.

HIP Enrollment Form

Please fax it to HIP at (646) 447-3185.

Check if your provider id is ready submit with our submitter id please call

GHI Medicare (Queens County - National Government Services) Enrollment Form

Please fax the form to the following fax number:

   315-442-4414

Please make sure that our submitter ID NYBQ11383 can be recognized on the form