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Forms

click here to Submit Documents

Active

Health Benefits Application

Change of Address

Summary of Benefits

NYC offered health plans

Surgical Anesthesia Form-ACTIVE MEMBERS ONLY

Retirees

Change of Address Form

Electronic Fund Transfer Form

Medicare Part B Reimbursement Application

NYC offered health plans

Medical/Dental

IRMAA Reimbursement Form

Dental Benefits Form

Dental Enrollment

Checklists

Divorce Checklist

Domestic Partnership Checklist

New Baby Checklist (Active and Retired)

Newly Wed Checklist (Active and Retired)