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

When applications are received after the 15th of the month, coverage will be effective on the first day of the following month.

Catastrophe Major Medical (Marsh Affinity)
Includes application and plan brochure

COBRA

Delta Dental Enrollment Form

Delta Disenrollment Form

 Domestic Partner/ Same Sex Spouse Benefits Application

Extended Disability Enrollment Form Disability enrollment is submitted to the PSC-CUNY Welfare Fund, 61 Broadway, 15th floor, New York, 10006.

Please include the Payroll Deduction Authorization card.

Extended Disability Medical Questionnaire, NY residents, NJ residents, CT residents, PA residents
Please submit the Medical form to the carrier. Address is on the form.

Extended Disability Certificate

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Payroll/Pension Deduction Authorization forms

    NYSUT Member Benefits Trust Payroll Deduction Authorization 
    This Form is required to pay premiums on any of these voluntary benefits: Life Insurance, 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

Catastrophe Major Medical (Marsh)
 (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 retirees (Plan 70 and 80, 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.

     Extended Disability Certificate

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 Summary Plan Description) are eligible only for a drug reimbursement.  This does not apply to most retirees, who participate in Medco or other plans.

Extended Medical 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

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

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.

    Optical Benefits EOBs: Please allow 6 weeks. Here's Why
Wellness

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INSURANCE CERTIFICATES

BENEFICIARY DESIGNATION FORMS

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