Welfare Fund Forms

All Welfare Fund forms are in PDF format. To download a free copy of Adobe Reader, click here.

Albert Shanker College Scholarship Fund Application

Anesthesia Benefit Claim Form - HIP Subscribers Only (30.5KB)

HIPAA: Privacy Practices Statement (57.3KB)

HIPAA: Personal Representative Form (PR Form) (16.2KB)

HIPAA: Protected Health Information Authorization Form (PHI Form) (32.4KB)

Dental Schedule Effective 07/01/06 (4.2KB)

Dental Claim Form Instructions (54.3KB)

Dental Claim Form (52.3KB)

Dental Enroll/Transfer Form (61.9KB)

Dependent Child Affidavit (25.2KB)

Dependent Student Certification Form (33.6KB)

Diabetes Drug Refund Form

Direct Access Dental Plan

Direct Access Rx Enrollment Form

Direct Access Rx Plan Q & A

Direct Drug Reimbursement Form (27.7KB)

Disabled Dependent Child Affidavit (32.1KB)

Durable Medical Equipment Deductible Reimbursement Form (32KB)

Mandatory Generic Price Waiver Form (14.7KB)

Medicare Part D Creditable Coverage

Medicare Part D Reimbursement Claim Form

Optional Rider Claim Form For NON-NYC Health Insurance Plans

Optional Rider Claim Form For NYC Health Insurance Plans

Optional Rider Claim Questionnaire

Prescription Appliance and/or Medical Equipment Claim Form - HIP Subscribers Only (28.3)

Pre-Office Visit Form

Personal Medication Question Guide Form

Speakers Bureau Request Form