NYC Health Benefit Plan enrollment forms, Welfare Fund Enrollment forms and Change of Status forms are only available through your campus benefits office because they must be validated by your benefits coordinator. 

If you are unable to print the forms below, your computer may need an additional program. It is available free by clicking here.

Enrollment Forms

    Adjunct Health Insurance Coverage
    This form is submitted to your campus benefits office, along with enrollment forms for HIP Prime or Empire Blue Cross HMO, PPO or EPO.

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Payroll/Pension Deduction Authorization forms

    NYSUT Payroll Deduction Authorization 
    This Form is required to pay premiums on any of these voluntary benefits: Life Insurance (after the first year), Catastrophic Medical Coverage and Long-Term Care..  It may also used to pay for other benefits through the NYSUT Benefit Trust. This Form is to be returned to the appropriate party to assure the correct process.

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REIMBURSEMENT CLAIM FORMS

       Catastrophic Major Medical (Marsh)

                 Catastrophe Policy Claim form  (note: administered by U.S. Life)

    Dental Claims

    DeltaCare USA members do not need claim forms for regular care.  Emergency Claim Forms (Reimbursed up to $100) are available from Delta here.

    Retirees:  Certain (Plan 70 and 80) retirees (see the SPD) are eligible only for a dental reimbursement.  (This does not apply to most retirees, who participate in either the Delta or Guardian plans above.)

        Disability Claims

      Claim forms are available from Standard Life Insurance Company, phone 1-888-689-1698. Forms are available from your campus benefits office after one year of service.

    Drug Claims

    Medco.  Members of Medco either use their Drug Card at a pharmacy or use Mail Order.  The most cost-effective way to buy long-term medications is to use Mail Order.  The Medco website is at www.medco.com.  

    Plan participants who have already purchased drugs use the Direct Claim reimbursement form below.

    Retirees.  Certain retirees (see the SPD) are eligible only for a drug reimbursement.  (This does not apply to most retirees, who participate in Medco or other plans.)

    Extended Medical Claim Forms

    When submitting this form, you must also include a GHI Explanation of Benefits (EOB) form and an Itemized Bill from your doctor/provider that includes descriptions of service and procedure codes. 

    Hearing Aid

        John Hancock Long Term Care

    No Claim Form is necessary when using General Vision Services or Davis Vision.

    Wellness

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INSURANCE CERTIFICATES

BENEFICIARY DESIGNATION FORMS

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