Health forms

Print
View, download and/or print current Health Plan forms.  
 
AFTRA H&R general forms
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 Performer Registration Form
pdficon_small Performer Address Change Form
pdficon_small Earnings Discrepancy Form 
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Puerto Rico Declaration of Covered Earnings and Address Update Form

 
AFTRA Health Plan forms
pdficon_small  Health Plan Enrollment Form
pdficon_small  Beneficiary Designation Form
pdficon_small  Other Health Insurance Form
pdficon_small  Dependent Change Form
pdficon_small  Medical Claim Form (use for dates of service on or after 1/1/15)
pdficon_small  Dental Claim Form
pdficon_small  Health Plan Premium Deduction from Pension Benefit Form
pdficon_small  Senior Citizen Health Program Enrollment Form
pdficon_small  Employer Request for Staff Performer Coverage Form (to be completed by employers)
pdficon_small  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 
pdficon_small  COBRA Continuation Coverage Election Form

Health Plan procedures
pdficon_small  Procedures to request Certificates of Creditable Coverage
 
Privacy forms
pdficon_small  Authorization Form
pdficon_small  Request for Confidential Communications
pdficon_small  Authorization Revocation
pdficon_small  Request for Access to Protected Health Information
pdficon_small  Request for Amendment of Protected Health Information


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

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

 

pdficon_small 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.