Popular CSEA EBF Forms
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Current Forms Available
- Universal Enrollment Form (56k)
The CSEA EBF Enrollment Form has been recently updated - Annual Physical Voucher (108k)
Reimburses cost of an annual physical not covered under health insurance - Change in Address Form (52k)
Form used for members to submit their address change. - Disability Form (96k)
Used to continue coverage for a dependent over 19 with a disability - UCS and Local Government Legal Claim Form (68k)
Used by UCS and Local Government Members - Prescription Drug Co-Pay (for NYS Employees) (52k)
Reimburses prescription drug co-payments once annually - Proof of Dependency (996k)
Used to provide proof of dependency for children under age 19 - Remove Dependent Form (76k)
Used to delete a dependent spouse or child - Student Proof (28k)
Used to continue coverage for a dependent over 19 that is a full time student - UCS/Retiree/Local Government Co-Pay Claim Form (44k)
Unified Court System and Local Government co-pays/maternity/hearing aid - UCS Combined Co-Pay form (74k)
Combined Co-Pay form for UCS members - Vision Care Reimbursement Form (44k)
If you use an outside provider you can submit this form for reimbursement - HIPAA Release Form (21k)
Form Required by the Privacy Regulations Promulgated Pursuant to the Health Insurance Portability and Accounability Act of 1996 - Hearing Aid Claim Form (48k)
Form that needs to be completed to apply for hearing aids. - Maternity Claim Form (48k)
Form that is used to apply for maternity benefit.