Forms: For Members | 1199SEIU Family of Funds

1199SEIU Family of Funds. Caring for Those who Care for Others.

Forms: For Members

General
Healthcare and Other Benefits
Pension & Retirement
Child Care & Youth Programs

General

Change of Address - Active Members
Change of Address - Retirees

Healthcare and Other Benefits

National Benefit Fund

Accidental or Occupational Disease Compensation Report
Authorization for Release of Protected Health Information
Dental Claim Form
Disability Claim Form
Benefits and Pension Enrollment Form
Employer's Disability Statement
Enrollment Change Form
Hearing Aid Form
Home Oxygen Therapy Request for Authorization
Mail Order Prescription Form
Medical Reimbursement Claim Form
Medicare Part B Reimbursement Form
Medical Proof of Change in Condition in Support of Application for Reopening Claim
Member Choice Enrollment Form
Prescription Reimbursement Form (Primary, COB, Foreign)
Prescription Request for Authorization
PT/OT/ST Benefit Extension Request Form
Service/Equipment Request for Authorization
Supplemental Medical Information-OBGYN
Supplemental Medical Information-Phyiscal Medicine and Rehabilitation
State of New York Workers' Compensation- Claimant's Request for Further Action
State of New York Workers Compensation - Employees Claim for Compensation
State of New York Workers' Compensation - Medical Proof of Change in Condition

Greater NY

Authorization for Release of Protected Health Information
Benefits and Pension Enrollment Form
Enrollment Change Form
Member Choice Enrollment Form

Home Care Benefit Fund

Authorization for Release of Protected Health Information
Benefits and Pension Enrollment Form
Enrollment Change Form

Home Health Aide Benefit Fund

Authorization for Release of Protected Health Information

Pension & Retirement

Health Care Employees Pension Fund

Application for Early or Normal Pension
Application for Pension Disability Benefit
Direct Deposit Form
Hospital Inquiry Form
Pension Beneficiary Option Form

Greater NY

Greater NY Application for Pension
Greater NY Pension Payment Option

Home Care

Beneficiary Form for Single Working Members
Direct Electronic Deposit Authorization
Home Care Agency Inquiry Form
Parent Guardian Affidavit Form
Pension Application Form
Proof of Age Form
Spouse Affidavit Form
Request for Pension Estimate Form

Child Care & Youth Programs

Camp Applications
Camp Application- English
Camp Application- Spanish

Joseph Tauber Scholarship

Joseph Tauber Scholarship Program -Request for Application- English
Joseph Tauber Scholarship Program-Request for Application- Spanish