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1099 Correction Form
1199SEIU Preferred Drug List
Authorization for Release of Protected Health Information
Change of Address – Active Members
Change of Address – Retirees
HIPAA Authorization Form
Parent and Guardian Affidavit
Request for Pension Estimate
Request for Social Security Earnings
National Benefit Fund
Accidental or Occupational Disease Compensation Report
Authorization for Release of Protected Health Information
Benefits and Pension Enrollment Form
Coordination of Benefits Form for Spouse Coverage
Coordination of Benefits Form for Young Adult Coverage
Disability Claim Form
Enrollment Change Form
GHI Dental Enrollment Form (NBF Rochester only)
Home Oxygen Therapy
Mail Order Prescription Form
Medicare Part B Reimbursement Form
Medical Proof of Change in Condition in Support of Application for Reopening Claim
Member Choice Enrollment Form
Notice and Proof of Claim for Disability Benefits
Prescription Reimbursement Form (Primary, COB, Foreign)
Prescription Authorization Request
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 of Claim for ESRD Medicare Part B Active Members
Supplemental Medical Information-OBGYN
Supplemental Medical Information-Physical Medicine and Rehabilitation
Young Adult Enrollment Form
Greater NY
Authorization for Release of Protected Health Information
Benefits and Pension Enrollment Form
Claim for Medicare Part D Reimbursement
Coordination of Benefits Form for Spouse Coverage
Coordination of Benefits Form for Young Adult Coverage
Enrollment Change Form
GHI Dental Enrollment Form
Member Choice Enrollment Form
Spouse Enrollment and Paycheck Deduction Authorization Form
Statement of Claim for ESRD Medicare Part B Active Members
Young Adult Enrollment Form
Greater New York Benefit Fund for New Jersey Area Members
Coordination of Benefits Form for Spouse Coverage
Home Care Benefit Fund
Authorization for Release of Protected Health Information
Enrollment Form
Plan Election Form
Home Health Aide Benefit Fund
Authorization for Release of Protected Health Information
Licensed Practical Nurses Welfare Fund
Coordination of Benefits Form for Spouse Coverage
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 Beneficiary Form – Basic Deferred Pension
Pension Option and Beneficiary Form
Greater NY
Application for Normal, Early Pension, or Disability
Direct Deposit Form
Pension Option and Beneficiary Form
Home Care
Agency Inquiry Form
Application for Normal, Early Pension or Disability
Beneficiary Form for Single Working Members
Direct Deposit 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