View, download and/or print current Health Plan forms.
AFTRA H&R general forms Performer Registration Form Performer Address Change Form - Version 1 (form fields may be completed on a computer) Performer Address Change Form - Version 2 (higher quality for printing multiple quantities)
AFTRA Health Plan forms Performer Enrollment Form Dependent Change Form Medical Claim Form Dental Claim Form Health Plan Premium Deduction from Pension Benefit Senior Citizen Health Program Enrollment Form Employer Request for Staff Performer Coverage Form (to be completed by employers) 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 COBRA Continuation Coverage 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
Through its relationship with Cigna, the AFTRA Health Plan is pleased to offer its enrollees discounted prices on all digital and digitally programmable hearing aids purchased through HearPO on or after Sept. 1, 2014.
This Update includes important announcements for Health and Retirement Plan participants.