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Forms

Forms for Enrolling
Welfare Fund BenefitsSend 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)
Optional BenefitsSend 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 BenefitsSend 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 BenefitsSend 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 BenefitsSend 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
 

Hollace Humphrey
The City University of New York
395 Hudson Street
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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