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Healthcare and Other Benefits

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 Young Adult Coverage
Disability Claim Form
Enrollment Change Form
GHI Dental Enrollment Form (NBF Rochester only)
Home Oxygen Therapy
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
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 Worker’s 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 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

Home Care Benefit Fund

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

Home Health Aide Benefit Fund

Authorization for Release of Protected Health Information