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General

1099 Correction Form
1199SEIU Preferred Drug List
Authorization for Release of Protected Health Information
Change of Address – Active Members
Change of Address – Retirees
Parent and Guardian Affidavit
Request for Pension Estimate
Request for Social Security Earnings


 

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
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
Medical Proof of Change in Condition in Support of Application for Reopening Claim
Member Choice Enrollment Form
Member Reimbursement Medical Claim Form
Montefiore Coordinated Care Program Opt-In Form
Montefiore Coordinated Care Program Opt-Out 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
Statement Claim for Hospital – Indemnity Benefit for National Benefit Fund Wage Class III Members
Statement of Claim for Medicare Part B Reimbursement Form
Statement of Claim for Medicare Part D Reimbursement Form
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
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
Montefiore Coordinated Care Program Opt-Out Form
Spouse Enrollment and Paycheck Deduction Authorization Form
Statement of Claim for ESRD Medicare Part B Active Members
Statement Claim for Hospital – Indemnity Benefit for Greater New York Fund Eligibility Class III Members
Statement of Claim for Medicare Part D Reimbursement Form

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


 

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

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

Former Home Care Industry Pension Fund

Pension Option and Beneficiary Form
Small Annuity Cash Out


 

Training & Employment

Enrollment Form – Training and Employment Funds Only