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  • Empire Plan Claim Form - Swboces 2014

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HEALTH INSURANCE CLAIM FORM. 1, MEDICARE MEDICAID cI IAMPUs CHAMPVA GROUP FECA OTHER 1a. INsURED's I.D. NUMBER (FDR PRDGRAM.

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Empire payer name and ID: Your Payer Name is Empire BlueCross BlueShield HealthPlus. Your Payer ID is 27514.

Empire Plan Medical/Surgical Program: To obtain medical claims information, outpatient physical therapy information or subrogation information, contact: UnitedHealthcare P.O. Box 1600 Kingston, NY 12402-1600.

For 2023, the maximum out-of-pocket limit for covered, in-network services under The Empire Plan is $9,100 for Individual coverage and $18,200 for Family coverage, split between the Hospital, Medical/Surgical, Mental Health and Substance Use and Prescription Drug programs.

The Empire Plan is designed to provide enrollees with comprehensive medical care coverage. Using participating providers helps keep the cost to you and The Empire Plan at a reasonable level. UnitedHealthcare is the program administrator for this coverage.

What is The Empire Plan? A. The Empire Plan is NYSHIP's unique health insurance plan designed exclusively for New York State's public employees and employers. The Empire Plan pays for covered hospital services, physicians' bills, prescription drugs and other covered medical expenses.

The Empire Plan is NYSHIP's unique health insurance plan designed exclusively for New York State's public employees and employers. The Empire Plan pays for covered hospital services, physicians' bills, prescription drugs and other covered medical expenses.

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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
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
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 workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
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