Popular CSEA EBF Forms
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Current Forms Available
- Universal Enrollment Form (87k)
The CSEA EBF Enrollment Form has been recently updated - Annual Physical Voucher (49k)
Reimburses cost of an annual physical not covered under health insurance - Change in Address Form (62k)
Form used for members to submit their address change. - Disability Form (78k)
Used to continue coverage for a dependent over 19 with a disability - UCS and Local Government Legal Claim Form (47k)
Used by UCS and Local Government Members - Prescription Drug Co-Pay (for NYS Employees) (55k)
Reimburses prescription drug co-payments once annually - Proof of Dependency (82k)
Used to provide proof of dependency for children under age 19 - Remove Dependent Form (80k)
Used to delete a dependent spouse or child - Student Proof (39k)
Used to continue coverage for a dependent over 19 that is a full time student - UCS/Retiree/Local Government Co-Pay Claim Form (98k)
Unified Court System and Local Government co-pays/maternity/hearing aid - UCS Combined Co-Pay form (63k)
Combined Co-Pay form for UCS members - Vision Care Reimbursement Form (67k)
If you use an outside provider you can submit this form for reimbursement - HIPAA Release Form (35k)
Form Required by the Privacy Regulations Promulgated Pursuant to the Health Insurance Portability and Accounability Act of 1996 - Hearing Aid Claim Form (46k)
Form that needs to be completed to apply for hearing aids. - Maternity Claim Form (46k)
Form that is used to apply for maternity benefit.