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)
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) Medical History Electronic Submission Our Plan Number is 430209	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	Mail the completed form with your invoice to the address on the invoice
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 P.O. Box 981572 El Paso. Texas 79998-1572
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.
High-Cost Rx Program Reimbursement Claim Form	Administrative Services Only, Inc P.O. Box 9009, Department # 178 Lynbrook, NY 11563-9009 1-877-362-2869
Optional Benefits	Send To
Catastrophe Major Medical Insurance Claim Form	The United States Life Insurance Company P.O. Box 1868 London, KY 40743 Email: emm_claims@aig.com

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 Benefits Office 395 Hudson Street New York, NY 10014 Email to universitybenefits.retiree@cuny.edu
Medicare Part B Reimbursement for TRS Members	NYC Health Benefits Program Attn: Medicare Unit 22 Cortlandt Street, 12th Floor New York, NY 10007
Medicare Part B IRMAA Surcharge Reimbursement form for: 2017, 2018, 2019	Please submit your IRMAA form and the requested documents (as a photo) to *NYCRetireesHBP@emblemhealth.com*. Include your pension number (if you have one). Include only the last 4 digits of your SSN on the form. Reimbursement for 2019 will be issued in October 2020
Medicare Part B Differential Reimbursement forms: 2017 2018 2019	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 Adjunct COBRA for use as of July 1 2020	PSC-CUNY Welfare Fund 61 Broadway, 15th floor New York, NY 10006
Welfare Fund Full-Time COBRA Full-Time COBRA for use as of July 1 2020	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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