Forms

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Select a topic below to find answers to some of the questions we hear most often. If you don’t find an answer to a question you have, please submit it to communications@psccunywf.org.

Forms to use for:

Forms for Enrolling
Forms for Claiming Benefits
Other Forms

Forms for Enrolling

Welfare Fund Benefits	Send To
WF Supplemental Benefits Enrollment Form	Your Campus Benefits Office
WF Supplemental Benefits Application for Domestic Partner	Your Campus Benefits Office
WF Adjunct Supplemental Benefits Enrollment Form	Your Campus Benefits Office
WF Adjunct Family Supplemental Benefits Enrollment Form	Your Campus Benefits Office

Optional Benefits	Send To
Extended Long Term Disability Enrollment Form	PSC-CUNY Welfare Fund 25 Broadway New York, NY 10004
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.) Hancock Long-Term Care Claim Information: 888-513-2071	Administrator PSC-CUNY Group Insurance Program P.O. Box 10374 Des Moines, IA 50306-0374
Payroll Deduction Authorization	Mail the completed form with your invoice to the address on the invoice.
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
NYCHBP Application	Retirees: Forms/documents must be submitted electronically using this NYC Health Benefits Program link.
How to Use LeapFILE to Submit Forms and Documents Electronically (Instructions and Videos)

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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	Guardian Group Dental Claims P.O. Box 981572 El Paso, TX 79998-1572
Dental Reimbursement Form (Retiree Plan 70) Call the PSC-Welfare Fund at 212-354-5230 or email communications@psccunywf.org for information.	PSC-CUNY Welfare Fund 25 Broadway New York, NY 10004
Dental Reimbursement Form (Retiree Plan 80) Call the PSC-Welfare Fund at 212-354-5230 or email communications@psccunywf.org for information.	PSC-CUNY Welfare Fund 25 Broadway New York, NY 10004
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 25 Broadway New York, NY 10004
Prescription Drug Reimbursement Form (Retiree Plan 70) Call the PSC-Welfare Fund at 212-354-5230 or email communications@psccunywf.org for information.	PSC-CUNY Welfare Fund 25 Broadway New York, NY 10004
Extended Medical Benefit Claim Form	Administrative Services Only, Inc Department # 178 P.O. Box 9009 Lynbrook, NY 11563-9009
Hearing Aid Reimbursement Call TruHearing at 877-653-8967 to obtain the reimbursement form.	Email or mail the completed form to: oonclaims@truhearing.com TruHearing Inc. Attn: Billing 12936 Frontrunner Blvd #100 Draper, UT 84020
High-Cost Rx Program Reimbursement Claim Form	Email Jennifer Melfi, jmelfi@psccunywf.org

Optional Benefits	Send To
Catastrophe Major Medical Insurance Claim Form	AIG/The United States Life Insurance Company P.O. Box 81879 Cleveland, Ohio 44181-1879 Email: emm_claims@aig.com

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Other Forms

Misc. 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	Forms/documents must be submitted electronically using this NYC Health Benefits Program link. How to Use LeapFILE to Submit Forms and Documents Electronically (Instructions and Videos)
Dental Reimbursement Form (Retiree Plan 80)	PSC-CUNY Welfare Fund 25 Broadway New York, NY 10004
Medicare Part B IRMAA Surcharge Reimbursement Form: 2021, 2023, 2023	Please submit this form, along with all required documents, electronically to: https://nycemployeebenefits.leapfile.net Or, mail to: NYC Health Benefits Program, ATTN: IRMAA 22 Cortlandt Street, 12th Floor New York, NY 10007
Medicare Part B Differential Reimbursement Forms: 2018, 2019	Forms/documents must be submitted electronically using this NYC Health Benefits Program link. How to Use LeapFILE to Submit Forms and Documents Electronically (Instructions and Videos)
SilverScript Med D Prescription Drug Claim Form	CVS Caremark PO Box 52066 Phoenix, AZ 85072-2066
Adjunct COBRA Continuation Enrollment	PSC-CUNY Welfare Fund P.O. Box 23565 New York, NY 10087-3565
Full-Time COBRA Continuation Enrollment	PSC-CUNY Welfare Fund P.O. Box 23565 New York, NY 10087-3565
Blue Cross Overseas (International) Hospital Claim Form	BlueCard Worldwide Service Center P.O. Box 261630 Miami, FL 33126 USA
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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