Forms

Forms for Enrolling
Welfare Fund Benefits	Send To
WF Supplemental Benefits Enrollment Form	Your Campus Benefits Office
WF Adjunct Supplemental Benefits Enrollment Form	Your Campus Benefits Office(s)
WF Adjunct Family Enrollment Supplement Form	Your Campus Benefits Office(s)
WF Supplemental Benefits Application for Domestic Partner	PSC-CUNY Welfare Fund 61 Broadway, 15th Floor New York, NY 10006
Optional Benefits	Send To
Extended Long Term Disability Enrollment Form	PSC-CUNY Welfare Fund 61 Broadway, 15th Floor New York, NY 10006
Medical History (NY) Medical History (NJ) Medical History (CT) Medical History (PA)	The Standard Life Insurance Company of New York Medical Underwriting 900 SW Fifth Avenue Portland, OR 97204
NYSUT Member Benefits Term Life Insurance	Mercer Consumer P.O. Box 9186 Des Moines, IA 50306-9186
Catastrophic Major Medical Insurance Application (For information purposes only. Enrollment is currently closed.)	Administrator PSC-CUNY Group Insurance Program P.O. Box 10374 Des Moines, IA 50306-0374
Payroll Deduction Authorization Pension Deduction Authorization	Administrator PSC-CUNY Group Insurance Program P.O. Box 10374 Des Moines, IA 50306-0374
NYC Basic Benefits	Send To
NYCHBP Application	Actives: Campus Benefits Office Retirees: City of New York Health Benefits Program 40 Rector Street - 3rd Floor New York, New York 10006

Forms For Claiming Benefits
Welfare Fund Benefits	Send To
Temporary CVS/Caremark Rx Drug Card
Delta Dental Claim Form	Delta Dental of NY, Inc. PO Box 2105 Mechanicsburg, PA 17055
Guardian (non-participating) Dental Reimbursement Claim Form	Group Dental Claims PO Box 2459 Spokane, WA 99210
Dental Reimbursement Form (Retiree Plan 70)	PSC-CUNY Welfare Fund 61 Broadway, 15th Floor New York, NY 10006
Dental Reimbursement Form (Retiree Plan 80)	PSC-CUNY Welfare Fund 61 Broadway, 15th Floor New York, NY 10006
Vision Benefit Reimbursement Form (Your Member ID# is your Social Security# unless you have specifically asked Davis to change it to another number.)	Vision Care Processing Unit P.O. Box 1525 Latham, NY 12110 tel: 800-283-9374 fax: 888-328-4761
CVS/Caremark Prescription Drug Claim Form	CVS Caremark PO Box 52136 Phoenix, AZ 85072-2136
SilverScript Med D Prescription Drug Claim Form	CVS Caremark PO Box 52066 Phoenix, AZ 85072-2066
Prescription Drug Exemption Request Form	PSC-CUNY Welfare Fund 61 Broadway, 15th floor New York, NY 10001
Prescription Drug Reimbursement Form (Retiree Plan 70)	PSC-CUNY Welfare Fund 61 Broadway, 15th Floor New York, NY10006
Extended Medical Benefit Claim Form	Administrative Services Only, Inc Department # 178 P.O. Box 9009 Lynbrook, NY 11563-9009
Hearing Aid Reimbursement	For out-of-network claims first contact HearUSA at 1-800-442-8231 prior to your appointment to be eligible for a maximum $500 direct reimbursement.
Optional Benefits	Send To
Catastrophe Major Medical Insurance Claim Form	The United States Life Insurance Company 3600 Route 66 P.O. Box 1581, MSN 2-E Neptune, NJ 07754-1581

Other Forms
	Send To
Beneficiary Designation Card	Campus Benefits Office
Parental Leave Application	Chair/unit head for approval and then forward approved leave to the Human Resources Department
Medicare Part B Reimbursement for TIAA-retirees	The City University of New York, University Employee Benefits Office, 395 Hudson Street, 5th Floor, New York, NY 10014
Medicare Part B IRMAA Surcharge Reimbursement forms: 2014 2015 2016 2017	Office of Labor Relations Health Benefits Program 40 Rector St., 3rd floor New York, NY 10006
Medicare Part B Differential Reimbursement forms: 2016 2017	NYC Health Benefits Program Attention: Medicare Part B Differential Unit Church Street Station PO Box 3478 New York, NY 10008-3478
Welfare Fund Adjunct COBRA enrollment UNTIL July 1, 2018 Welfare Fund Adjunct COBRA enrollment AFTER July 1, 2018	PSC-CUNY Welfare Fund 61 Broadway, 15th floor New York, NY 10006
Welfare Fund Full-time COBRA enrollment UNTIL July 1, 2018 Welfare Fund Full-time COBRA enrollment AFTER July 1, 2018	PSC-CUNY Welfare Fund 61 Broadway, 15th floor New York, NY 10006
Healthcare Proxy info, form & instructions	The New York Health Care Proxy Law allows you to appoint someone you trust - for example, a family member or close friend - to make health care decisions for you if you lose the ability to make decisions yourself.

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