Health forms


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

AFTRA H&R general forms
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 Health Plan Enrollment Form
Adobe .PDF icon Beneficiary Designation Form
Adobe .PDF icon Other Health Insurance Form
pdf_icon Dependent Change Form

Adobe .PDF icon Medical Claim Form (use for dates of service on or after 1/1/15)
pdf_icon Medical Claim Form (use for dates of service before 1/1/15)
pdf_icon Dental Claim Form
pdf_icon Health Plan Premium Deduction from Pension Benefit Form
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 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

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

AIG Benefit Solutions life insurance and accidental death and personal loss coverage forms

pdf_icon   Proof of Group Death Claim and Fraud Statement
pdf_icon   Preference Beneficiary Affidavit

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.