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 (highest quality for printing multiple quantities)
AFTRA Health Plan forms Performer Enrollment Form Medical Claim Form Dental Claim Form Full-Time Student Verification Form Health Plan Premium Deduction from Pension Benefit Senior Citizen Coverage Request Form CIGNA Provider Nomination 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 ChecklistSame-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
8/04/2010
Summary ... Effective Jan. 1, 2011, Health Plan participants will use CIGNA PPO to choose network providers in all 50 states.
7/01/2010
Summary ... Mr. Stephen Mirante of CBS Corp. and Mr. Ron Wilcox of Warner Music Group have joined AFTRA H&R’s Board of Trustees.