Benefits Fund Forms

Benefits Fund participants may download PHI Authorization and Physician Nomination 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, including Enrollment forms, should be mailed to the address specified on the form. Photos are not accepted for Enrollment forms.

Medical, Dental, Rx, Vision

Form Name (click or tap to view) Description (click or tap to download)
Aetna Claim Form Dental care Claim Form
Empire BlueCross BlueShield Claim Form Submit a medical claim under Empire
Empire Gym Reimbursement Program Reimbursement for health club/gym membership
Empire BlueCross BlueShield Transition of Care Form Request transition of medical care from an out-of-network provider
ESI Home Delivery Order Form Rx mail-order forms for maintenance meds
ESI Prescription Drug Reimbursement Form Reimbursement for Prescription Drugs
Davis Vision Claim Form Vision Care form
Oxford Claim Form Medical claim form
PHI Authorization Authorization form for the Disclosure of personal health information

Disability Forms

Form Name (click or tap to view) Description (click or tap to download)
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
Open Enrollment Form 2022 For use between Nov. 1 to Dec. 31 for coverage effective date Jan. 1, 2023
Enrollment Form Used to enroll in the Benefits Fund. (You must mail or fax this form. Photos are not accepted.)
Opt Out Application As outlined in your CBA, you may be able to waive Benefits Fund health coverage as long as you have coverage through another health plan