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

AFTRA H&R general forms
 Performer Registration Form 

AFTRA Health Plan forms
 Performer Enrollment Form - Version 1 (form fields may be completed on a computer) 
 Performer Enrollment Form - Version 2 (highest quality for printing multiple quantities)
 Medical Claim Form
 Dental Claim Form
 Full-Time Student Verification Form
 Health Plan Premium Deduction from Pension Benefit
 Senior Citizen Coverage Request Form

   
COBRA Premium Assistance* notices, forms and applications
* For eligible individuals as defined by the
American Recovery and Reinvestment Act of 2009 (ARRA)
  COBRA Notice of Rights
  COBRA Summary of Premium Reduction Provisions Under the ARRA
  COBRA ARRA - Request for Treatment as an Assistance Eligible Individual
  COBRA Premium Assistance Notice of Other Coverage
  Coordination of COBRA Premium Assistance with New York State Continuation Coverage
  COBRA Election Form

 
Health Plan procedures
 Procedures to request Certificates of Creditable Coverage


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


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


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


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

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.