Popular CSEA EBF Forms
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Current Forms Available
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1. Universal Enrollment Form (70k)
The CSEA EBF Enrollment Form has been recently updated -
2. Dental Claim Form (94k)
In addition to the EBF claim form, providers can submit claims electronically. Members can also use the ADA universal claim form that is available from your provider. -
3. Disability Form (137k)
Used to continue coverage for a dependent over 19 with a disability -
4. UCS and Local Government Legal Claim Form (877k)
Legal Services Voucher used by UCS and Local Government Members -
5. Prescription Drug Co-Pay (for NYS Employees) (214k)
Note: Must also submit itemized pharmacy printout -
6. Prescription Drug Co-pay- NYS Liquidation Bureau (215k)
Note: Must also submit itemized pharmacy printout -
7. Proof of Dependency (53k)
Used to provide proof of dependency for children under age 19 -
8. Remove Dependent Form (132k)
Used to delete a dependent spouse or child -
9. UCS Retiree Co-Pay Claim Form (203k)
Note: Must also submit itemized pharmacy printout -
10. Local Government Co-Pay Claim Form (196k)
Note: Must also submit itemized pharmacy printout -
11. UCS Combined Co-Pay form (202k)
Note: Must also submit itemized pharmacy printout -
12. Vision Care Reimbursement Form (168k)
If you use an outside provider you can submit this form for reimbursement -
13. HIPAA Release Form (877k)
Form Required by the Privacy Regulations Promulgated Pursuant to the Health Insurance Portability and Accountability Act of 1996 -
14. Hearing Aid Claim Form (206k)
Form that needs to be completed to apply for hearing aids. -
15. Maternity Claim Form (209k)
Form that is used to apply for maternity benefit. -
16. Solstice Enrollment Form (480k)
Form that is used to enroll in Solstice Dental or Vision plans. -
17. Recurring Payment Form (318k)
Form used for authorization of recurring payment of your benefits -
18. Annual Physical Voucher (139k)
Voucher for annual physical (Town of Southold only) -
19. Student Proof 2017-2018 (46k)
Student Proof Form for Fall 2017 - Spring 2018 -
20. Student Proof 2018-2019 (67k)
Student Proof Form for Fall 2018 - Spring 2019 -
21. Name Change Form (94k)
Form to submit a name change -
22. Change of Address (61k)
This form is used to submit a change of address.
