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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
