1199SEIU Funds. Caring for Those who Care for Others.

Forms: For Members



General


Change of Address - Active Members
Change of Address - Retirees


Healthcare and Other Benefits

National Benefit Fund
 
Accidental or Occupational Disease Compensation Report 
Authorization for Release of Protected Health Information 
Benefits and Pension Enrollment Form 
Disability Claim Form
Employer's Disability Statement
Enrollment Change Form 
Hearing Aid Form
Home Oxygen Therapy Request for Authorization
Mail Order Prescription Form 
Medical Reimbursement Claim Form
Medicare Part B Reimbursement Form
Medical Proof of Change in Condition in Support of Application for Reopening Claim
Member Choice Enrollment Form
Prescription Reimbursement Form (Primary, COB, Foreign)
Prescription Request for Authorization
PT/OT/ST Benefit Extension Request Form
Service/Equipment Request for Authorization
Supplemental Medical Information-OBGYN
Supplemental Medical Information-Physical Medicine and Rehabilitation
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 Worker's Compensation- Attending Doctor's Report

Greater NY 

Authorization for Release of Protected Health Information
Enrollment Change Form
Member Choice Enrollment Form

Home Care Benefit Fund

Authorization for Release of Protected Health Information
Benefits and Pension Enrollment Form
Enrollment Change Form

Home Health Aide Benefit Fund

Authorization for Release of Protected Health Information

Pension & Retirement

Health Care Employees Pension Fund

Application for Early or Normal Pension
Application for Pension Disability Benefit
Direct Deposit Form
Enrollment Form - Pension Fund Only
Pension Option and Beneficiary Form 

Health Care Employees Pension Fund
Former 144 Hospital Division

Application for Normal, Early Pension, or Disability
Pension Option and Benficiary Form - Basic Deferred Pension
Pension Option and Benficiary Form

Greater NY 

Application for Normal, Early Pension, or Disability 
Direct Deposit Form
Pension Option and Beneficiary Form

Home Care 

Application for Normal, Early Pension or Disability
Beneficiary Form for Single Working Members
Direct Deposit Form
Agency Inquiry Form 
Pension Estimate Request 
Parent Guardian Affidavit Form 
Pension Option and Beneficiary Form
Proof of Age Form 
Spouse Affidavit Form

Home Care
Former Home Care Industry Pension Fund

Pension Option and Beneficiary Form 
Small Annuity Cash Out


Training & Employment


Enrollment Form - Training and Employment Funds Only



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Training & Employment Funds
1199SEIU Child Care Funds