Nyc health benefits program forms

• [PDF File]Health and Welfare Fund

  https://info.5y1.org/nyc-health-benefits-program-forms_1_204bfd.html

  SECTION IV – Information About Other Health Plans/Insurance Coverage (Plans other than the City of New York Health Benefits Program) Do any of your dependents have coverage through another employer or union (This includes other NYC Union Health and Welfare Funds,

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• [PDF File]City of New York Health Benefits Program IRMAA Medicare ...

  https://info.5y1.org/nyc-health-benefits-program-forms_1_c2ddba.html

  Health Benefits Program 40 Rector Street, 3rd Floor New York, NY 10006 Attention: IRMAA IRMAA reimbursements checks will be issued beginning in March 2012. (Claims that do not include both documents for each eligible person and claims that include documents for years other than the years specified above WILL NOT BE EVALUATED.)

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• [PDF File]2019 Medicare Part B Premium Reimbursement - New York City

  https://info.5y1.org/nyc-health-benefits-program-forms_1_d21551.html

  New York City Office of Labor Relations Health Benefits Program . 22 Cortlandt Street - th 12 Floor . New York, NY 10007 . nyc.gov/hbp . 2019 Medicare Part B Premium Reimbursement . ANSWERS TO FREQUENTLY ASKED QUESTIONS . The standard reimbursement amount for Calendar Year 2019 is $109.00 per person, per month. For those

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• [PDF File]S.H.I.P. UFT SHIP

  https://info.5y1.org/nyc-health-benefits-program-forms_1_847015.html

  UFT/RTC Supplemental Health Insurance Program UFT SHIP 52 Broadway, 17th Floor New York, NY 10004 -9060 1. Accidental Death and Dismemberment: SHIP provides a benefit of $10,000 for accidental loss of life or loss of both limbs or both eyes. SHIP provides a …

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• [PDF File]Health Benefits Program Employees For ... - New York City

  https://info.5y1.org/nyc-health-benefits-program-forms_1_38b2b7.html

  I. TO PARTICIPATE IN THE HEALTH BENEFITS PROGRAM OR REQUEST CHANGES TO HEALTH COVERAGE ... I certify that the above employee/retiree is eligible for the New York City Health Benefits Program (HBP) and that dependent documentation has been verified in accordance with HBP ... h /olr ehb hba/2017 health benefits application.indd9/19.

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• [PDF File]NEW YORK CITY HEALTH BENEFITS PROGRAM (NYCHBP)

  https://info.5y1.org/nyc-health-benefits-program-forms_1_11bcfd.html

  NEW YORK CITY HEALTH BENEFITS PROGRAM (NYCHBP) The 2015 open enrollment period for the . New York City Health Benefits Program. will be from October 1. st. to October 30. During this time, employees may change plans, add or drop a rider and/or dependents.

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• [PDF File]Instructions for completing a Health Benefits Application ...

  https://info.5y1.org/nyc-health-benefits-program-forms_1_d73000.html

  Instructions for completing a Health Benefits Application (For Employees) (Please print all information clearly using a black or blue ballpoint pen) Check the EMPLOYEE box at the top of the form. Sections A, B & C: Check off the reason for submission of this form.

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• [PDF File]UFT/RTC Supplemental Health Insurance Program (SHIP)

  https://info.5y1.org/nyc-health-benefits-program-forms_1_d23326.html

  Claims must be filed within 1 year of the date of service or payment by health plan, whichever is later. SHIP Claim Form UFT/RTC Supplemental Health Insurance Program (SHIP) Mail to: SHIP 52 Broadway, 17th Floor New York, NY 10004 Telephone: 212-228-9060 Please read reverse side for required documents and benefit limitation before submitting claim.

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• [PDF File]Applicant MUST check one: EMPLOYEE Health Benefi ts ...

  https://info.5y1.org/nyc-health-benefits-program-forms_1_4f397c.html

  H. TO PARTICIPATE IN THE HEALTH BENEFITS PROGRAM - PLEASE SIGN & DATE BELOW (Participant must sign either Section H or I) I certify that the above information is correct and I authorize the City to deduct from my salary/pension the amount required, if …

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• [PDF File]City of New York Health Benefits Program Frequently Asked ...

  https://info.5y1.org/nyc-health-benefits-program-forms_1_cde03e.html

  notifying the Health Benefits Program and the applicable welfare fund within 60 days of the death, divorce, domestic partnership termination, or of a child’s losing dependent status. COBRA packages containing detailed information and an application can be obtained from the Health Benefits Program.

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