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 Health Plan Enrollment Form Beneficiary Designation Form Other Health Insurance Form Dependent Change Form
Medical Claim Form (use for dates of service on or after 1/1/15) Medical Claim Form (use for dates of service before 1/1/15) Dental Claim Form Health Plan Premium Deduction from Pension Benefit Form 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 AIG Benefit Solutions life insurance and accidental death and personal loss coverage forms Proof of Group Death Claim and Fraud Statement Preference Beneficiary Affidavit
Summary ... Performers should verify the accuracy of information on their Earnings Statements as soon as possible.
Summary … The Health Plan ID cards mailed in December are missing important info related to provider billing. Use updated ID mailed in April.