Forms For Members

General

1199SEIU Preferred Drug List
Authorization for Release of Protected Health Information
Change of Address – Active Members
Change of Address – Retirees
Parent and Guardian Affidavit

Healthcare and Other Benefits

National Benefit Fund

Accidental or Occupational Disease Compensation Report
Authorization for Release of Protected Health Information
Coordination of Benefits Form for Spouse Coverage
Coordination of Benefits Form for Young Adult Coverage
Disability Claim Form
Disability Supplemental Medical Information (SMI) General Form
Enrollment Form (Benefits and Pension)
Enrollment Change Form
GHI Dental Enrollment Form (NBF Rochester only)
Home Oxygen Therapy
Mail Order Prescription Form
Member Choice Enrollment Form
Medical Proof of Change in Condition in Support of Application for Reopening Claim
Member Reimbursement Medical Claim Form
Notice and Proof of Claim for Disability Benefits
Prescription Reimbursement Form (Primary, COB, Foreign)
Prescription Authorization Request
PT/OT/ST Benefit Extension Request Form
Service/Equipment Request for Authorization
State of New York Workers’ Compensation – Claimant’s Request for Further Action
State of New York Workers’ Compensation – Employees Claim for Compensation
State of New York Workers’ Compensation – Medical Proof of Change in Condition
State of New York Workers’ Compensation – Attending Doctor’s Report
Statement Claim for Hospital Indemnity Benefit
Statement of Claim for ESRD Medicare Part B Active Members
Statement of Claim for Medicare Part B Reimbursement Form
Statement of Claim for Medicare Part D Reimbursement Form
Supplemental Medical Information-OBGYN
Supplemental Medical Information-Physical Medicine and Rehabilitation

Greater New York

Authorization for Release of Protected Health Information
Coordination of Benefits Form for Spouse Coverage
Coordination of Benefits Form for Young Adult Coverage
Enrollment Form (Benefits and Pension)
Enrollment Change Form
GHI Dental Enrollment Form
Spouse Coverage and Payroll Deduction Authorization Form
Statement of Claim for ESRD Medicare Part B Active Members
Statement Claim for Hospital Indemnity Benefit
Statement of Claim for Medicare Part D Reimbursement Form

Greater New York Benefit Fund for New Jersey Area Members

Coordination of Benefits Form for Spouse Coverage
Enrollment Form (Benefits and Pension)
Enrollment Change Form

Home Care Benefit Fund

Authorization for Release of Protected Health Information
Benefit Enrollment Forms

Licensed Practical Nurses Welfare Fund

Coordination of Benefits Form for Spouse Coverage
Enrollment Form

Pension & Retirement

Health Care Employees Pension Fund

1099 Correction Form
Application for Early or Normal Pension
Application for Pension Disability Benefit
Authorization to Obtain Earnings Data from the Social Security Administration
Direct Deposit Form
Enrollment Form – Pension Fund Only
Pension Option and Beneficiary Form
Request for Pension Estimate

Former 144 Hospital Division

1099 Correction Form
Application for Normal, Early Pension, or Disability
Pension Option and Beneficiary Form – Basic Deferred Pension

Greater New York

1099 Correction Form
Application for Normal, Early Pension, or Disability
Authorization to Obtain Earnings Data from the Social Security Administration
Direct Deposit Form
Pension Option and Beneficiary Form

Home Care

1099 Correction Form
Agency Inquiry Form
Application for Normal, Early Pension or Disability
Authorization to Obtain Earnings Data from the Social Security Administration
Beneficiary Form for Single Working Members
Direct Deposit Form
Pension Estimate Request
Parent Guardian Affidavit Form
Pension Option and Beneficiary Form
Proof of Age Form
Spouse Affidavit Form

Former Home Care Industry Pension Fund

Pension Option and Beneficiary Form
Small Annuity Cash Out

Training & Employment

Enrollment Form – Training and Employment Funds Only