Embs form 2026

1. Click ‘Get Form’ to open the embs form in the editor.
2. Begin by filling out the Employee Information section. Enter your last name, first name, current mailing address, phone number, member ID number, and employer name.
3. If the patient is not the employee, complete the Patient Information section with their name, relationship to you, mailing address, date of birth, and gender.
4. For accident or occupational injury claims, provide details about the incident in the designated section. Indicate if it was work-related and describe briefly.
5. If applicable, fill out Family or Other Insurance Coverage Information for dependents. Include spouse employment status and any other insurance coverage details.
6. Review all information for accuracy. Sign and date both the Certification and Authorization sections to validate your claim.

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