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Forms

Forms for Enrolling
Welfare Fund BenefitsSend To
WF Supplemental Benefits Enrollment Form Your Campus Benefits Office
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
Delta Dental Enrollment Form PSC-CUNY Welfare Fund
61 Broadway, 15th Floor
New York, NY 10006
Delta Dental Disenrollment Form PSC-CUNY Welfare Fund
61 Broadway, 15th Floor
New York, NY 10006
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
Term Life Application and Policy Marsh U.S. Consumer,
a Service of Seabury & Smith, Inc.
P.O. Box 9186
Des Moines, IA 50306-9186

Catastrophic Major Medical Insurance Application

(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
Guardian Claim Form Group Dental Claims
PO Box 2459
Spokane, WA 99210
Delta Dental Claim Form Delta Dental of New York, Inc
PO Box 2105
Mechanicsburg, PA 17055
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
Prescription Drug Claim Form Medco Health Solutions, Inc.
PO Box 14711
Lexington, KY 40512
Direct Optical Reimbursement Form PSC-CUNY Welfare Fund
61 Broadway, 15th Floor
New York, NY10006
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 Form PSC-CUNY Welfare Fund
61 Broadway, 15th Floor
New York, NY 10006
Weight Watchers Claim Form PSC-CUNY Welfare Fund
61 Broadway, 15th Floor
New York, NY 10006
Optional BenefitsSend To
Catastrophic 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
Medco By Mail Order Form Medco Health Solutions of Dallas
P.O. Box 650322
Dallas, TX 75265-0322
Beneficiary Designation Card PSC-CUNY Welfare Fund
61 Broadway, 15th Floor
New York, NY 10006
Parental Leave Application Chair/unit head for approval and then forward approved leave to the Human Resources Department
Medicare Part B
Reimbursement for TIAA-CREF retirees 
The City University of New York
University Employee Benefits Office
395 Hudson St., 5th floor
New York, NY 10014
 

Medicare Part B IRMAA Surcharge Reimbursement (2013)

 

Office of Labor Relations
Health Benefits Program
40 Rector St., 3rd floor
New York, NY 10006 
Welfare Fund Adjunct COBRA
Continuation Enrollment 

PSC-CUNY Welfare Fund
61 Broadway, 15th floor
New York, NY 10006 

Welfare Fund COBRA
Continuation Enrollment

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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