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
90-Day Rx Solution Maintenance Drug Access Program Waiver Request Form

Healthcare and Other Benefits

National Benefit Fund

Accidental or Occupational Disease Compensation Report
Aetna Medicare Advantage Plan Opt-In Form
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 Claim – Direct Deposit Form
Disability Supplemental Medical Information (SMI) General Form
Enrollment Form (Benefits and Pension)
Enrollment Change Form
GHI Dental Enrollment Form (NBF Rochester only)
Humana Medicare Advantage Plan Opt-Out Form
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

Aetna Medicare Advantage Plan Opt-In Form
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
Dependent Child Enrollment Form
Life Insurance Beneficiary 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

Aetna Medicare Advantage Plan Opt-In Form
Affidavit for Unlocatable Spouse
Application for Normal or Early Pension
Application for Pension Disability Benefit
Direct Deposit Form
Enrollment Form – Pension Fund Only
Request for Pension Estimate
Statement of Claim for Medicare Part B Reimbursement Form

Former 144 Hospital Division

Application for Normal, Early or Disability Pension

Greater New York

Aetna Medicare Advantage Plan Opt-In Form
Affidavit for Unlocatable Spouse
Application for Normal, Early or Disability Pension
Direct Deposit Form
Request for Pension Estimate

Home Care

Affidavit for Unlocatable Spouse
Application for Normal, Early or Disability Pension
Beneficiary Form for Single Working Members
Direct Deposit Form
Request for Pension Estimate

Training & Employment

Enrollment Form – Training and Employment Funds Only

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