Health forms

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View, download and/or print current Health Plan forms.  

AFTRA H&R general forms
pdf_icon 
Performer Registration Form
pdf_icon Performer Address Change Form - Version 1 (form fields may be completed on a computer)
pdf_icon Performer Address Change Form - Version 2 (higher quality for printing multiple quantities)

 
AFTRA Health Plan forms

pdf_icon Performer Enrollment Form
pdf_icon Dependent Change Form
pdf_icon Medical Claim Form
pdf_icon Dental Claim Form
pdf_icon Health Plan Premium Deduction from Pension Benefit
pdf_icon Senior Citizen Health Program Enrollment Form
pdf_icon Employer Request for Staff Performer Coverage Form (to be completed by employers)
pdf_icon CIGNA Provider Nomination Form

Express Scripts forms
Visit and register with www.express-scripts.com to download current Express Scripts Pharmacy mail order forms (on the left menu, under “Prescriptions & benefits” select “Forms & cards” and then “Print a mailorder form by clicking here,”) and to access other resources and information from Express Scripts, Inc.

 

COBRA continuation coverage notice and election form 
pdf_icon  COBRA Continuation Coverage Election Form

 

 

Health Plan procedures
pdf_icon Procedures to request Certificates of Creditable Coverage


Same-sex domestic partner buy-up forms
(If you qualify for the Individual Health Plan)
pdf_icon Declaration Form
pdf_icon Checklist


Same-sex domestic partner family coverage forms
pdf_icon Declaration Form
pdf_icon Affidavit of "Dependency" for Tax Purposes
pdf_icon Checklist


Privacy forms
pdf_icon Authorization Form
pdf_icon Request for Confidential Communications
pdf_icon Authorization Revocation
pdf_icon Request for Access to Protected Health Information
pdf_icon Request for Amendment of Protected Health Information


Aetna life insurance and accidental death and dismemberment coverage forms
pdf_icon Proof of Death Form
pdf_icon Accelerated Death Benefit Form
pdf_icon Accidental Dismemberment /Personal Loss Claim Form
pdf_icon Attending Physician Statement

 

 

pdf_icon Note to View .PDF Files
The best way to print the forms is to download them as PDF files. To open the PDF file you will need Adobe Acrobat Reader which is available free.