Benefits Fund Forms

Benefits Fund participants may download PHI Authorization, Physician Nomination, and Eligibility forms below then simply fill out and sign your paperwork, take a picture, and e-mail it to benefitsdepartment@rnbenefits.org. Disability forms may be e-mailed to disability@rnbenefits.org. All other forms should be mailed to the address specified on the form.

Medical, Dental, Rx, Vision

Form Name (click or tap to view) Description (click or tap to download)
ESI Prescription Drug Reimbursement Form Reimbursement for Prescription Drugs
Oxford Sweat Equity Program Reimbursement for health club/gym membership
ESI Home Delivery Order Form Rx mail-order forms for maintenance meds
Aetna Claim Form Dental care Claim Form
Davis Claim Form Vision Care form
Oxford Claim Form Medical claim form
PHI Authorization Authorization form for the Disclosure of personal health information
Physician Nomination Recommend a physician to join Oxford Network

Disability Forms

Form Name (click or tap to view) Description (click or tap to download)
Hartford Short-term Disability Continued Attending physician’s statement of continued disability
Hartford Short-term Claim Notice and proof of claim for short-term disability benefits
Hartford Authorization Authorization form for the disclosure of personal health information
Hartford Long-term Claim Long-term disability claim statement
Hartford Accident Details Your disability may have been caused by an insured person who would have been liable to pay damages.
Hartford Mental Heath Statement Attending physician’s statement of continued disability for mental health
MetLife Attending Physician Statement Attending physician’s statement of continued disability
MetLife Short-term Claim Notice and proof of claim for short-term disability benefits
MetLife Authorization Authorization form for the disclosure of personal health information
MetLife EFT Authorization Authorization of direct deposit of disability payment
MetLife Psychiatric Questionnaire Attending physician’s statement of continued disability for mental health

Eligibility Forms

Form Name (click or tap to view) Description (click or tap to download)
Young Adult Form Dependents ages 26 through 29 are eligible for medical insurance only
Enrollment Form Used to enroll in the Benefits Fund