Forms

Enrollment Forms

Optional Disability Rider Enrollment Form

Optional Disability Rider Medical Questionnaire
Both Disability forms may be submitted to the PSC-CUNY Welfare Fund, 61 Broadway, 15th floor, New York, 10006. Or submit the Medical form to the carrier. Address is on the form. Please include the Payroll Deduction Authorization card.

Dependent Student Enrollment Form
For F/T students age 19 through 23.

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.

Empire Blue Cross Enrollment/Change Form

HIP Enrollment Form

Welfare Fund Full-time COBRA Enrollment

Welfare Fund Adjunct COBRA Enrollment

Catastrophic Major Medical
Includes application and plan brochure

Application for Benefits for Domestic Partners

Long Term Care

Click here for special website set-up by John Hancock for the long-term care program. You will need to enter a username (psccuny) and password (mybenefit).

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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.

NYSUT Pension Deduction Form
To pay premiums on voluntary benefits (e.g. Catastrophic Medical Coverage and Long-Term Care).

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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.

Guardian Non-Participating Dentist Form

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.)

Dental Reimbursement Form For Plan 70 Retirees

Dental Reimbursement Form For Plan 80 Retirees

        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.

Medco Mail Order Form

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

Medco Direct Claim Reimbursement Form

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.)

Prescription Drug Refund Form For Plan 70 Retirees

Extended Medical Claim Forms

ASO Extended Medical Benefit Claim Form

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

Hearing Aid Reimbursement Form

        John Hancock Long Term Care

Claim Forms for Long-Term Care are available from John Hancock, 1-888-513-2071

Medicare Part B For TIAA-CREF retirees

Application for Medicare Part B Premium Reimbursement

Medicare Part B IRMAA surcharge reimbursement

New York City Health Benefit Plan

GHI Health Insurance Claim Form

Optical

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

Direct Reimbursement for Other Qualified Vision Care

GVS $100 Bonus Check Towards an Additional Pair of Glasses

Wellness

Weight Watchers Reimbursement Form


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INSURANCE CERTIFICATES

Extended Disability Certificate

BENEFICIARY DESIGNATION FORMS

Death Benefit Beneficiary Designation Form