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
EmblemHealth Preferred Dental Transition of Care Form
Healthcare and Other Benefits
National Benefit Fund
Accidental or Occupational Disease Compensation Report
Authorization for Release of Protected Health Information
Benefit Fund Appeal Representation Authorization Form
Coordinated Care Program Opt-Out Form
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
EmblemHealth Transition of Care Request 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
Paid Family Leave Form
Prescription Reimbursement Form (Primary, COB, Foreign)
Prescription Authorization Request
Provider Recruitment Form
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
Benefit Fund Appeal Representation Authorization Form
Coordinated Care Program Opt-Out Form
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
Provider Recruitment 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
Benefit Fund Appeal Representation Authorization Form
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
Benefit Fund Appeal Representation Authorization Form
Coordinated Care Program Opt-Out Form
Provider Recruitment Form
Licensed Practical Nurses Welfare Fund
Authorization for Release of Protected Health Information
Benefit Fund Appeal Representation Authorization Form
Coordination of Benefits Form for Spouse Coverage
Enrollment Form
Pension & Retirement
Health Care Employees Pension Fund
1099 Correction Form
Affidavit for Unlocatable Spouse
Application for Normal or Early 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 or Disability Pension
Pension Option and Beneficiary Form – Basic Deferred Pension
Greater New York
1099 Correction Form
Affidavit for Unlocatable Spouse
Application for Normal, Early or Disability Pension
Authorization to Obtain Earnings Data from the Social Security Administration
Direct Deposit Form
Pension Option and Beneficiary Form
Request for Pension Estimate
Home Care
1099 Correction Form
Affidavit for Unlocatable Spouse
Agency Inquiry Form
Application for Normal, Early or Disability Pension
Authorization to Obtain Earnings Data from the Social Security Administration
Beneficiary Form for Single Working Members
Direct Deposit Form
Request for Pension Estimate
Pension Option and Beneficiary Form
Proof of Age Form
Former Home Care Industry Pension Fund
Pension Option and Beneficiary Form
Small Annuity Cash Out