Member Forms

Benefits Forms

• Annuity Plan Beneficiary Designation
• Caremark Prescription Drug Claim. Important: Caremark prescription drug claim form has changed: Your prescribing physician's information is now required. See Step 2 of the new form for updated submission requirements.
• Catastrophic Benefit Claim (Active members only)
• Change of Address
• Dental Claim
• Out-of-Network Dental Schedule for 2020
• Dependent Life Insurance Enrollment
• Enrollment (Active members only)
• Enrollment (Retirees only)
• Hearing Aid
• HIPAA Authorization
• Life Insurance Beneficiary Designation
• Medical Equipment Benefit
• Medicare Part B Reimbursement Differential Request Form 2019
• Vision Benefit - Direct Reimbursement Claim Form
• Reimbursement for Real Estate Legal Services

Legal Forms

Note: All forms directed to the Department must be typed. We have listed a series of forms, below, that will, among other things, make it easier for members to file grievances, challenge unlawful employment actions of the Department, assert rights under the Health and Safety Laws, and challenge evaluations.

• Appeal a Chronic Absent Designation
• DOH Physician Complaint Form and Instructions
• Equal Employment Opportunity Complaints
• Evaluation Appeal
• Family and Medical Leave Act
• Filing a Grievance
• Health and Safety Violation Complaint Form
• Motor Vehicle Accidents
• PESH Complaint
• Public Service Loan Forgiveness Employment Certification Form
• Real Estate Legal Services Claim
• Sealing Disciplinary Charges and Records; Expungment of Investigative Reports
• Summons Quota

World Trade Center

• Notice of Participation
• WTC Disability Witness Affidavit