Your Union.
Your Benefits.

Popular CSEA EBF Forms

Current Forms Available

• 1. 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. 2025 Prescription Drug Co-Pay (for NYS Employees) (66k)
  Note: Must also submit itemized pharmacy printout
• 4. UCS Full Time & Retiree Co-Pay Form (59kb)
  UCS Full Time & Retiree Co-Pay Form
• 5. Town of Ramapo Rx Copay Form (50kb)
  Town of Ramapo Prescription Drug Copay Form.
• 6. Local Government Co-Pay Claim Form (196k)
  Note: Must also submit itemized pharmacy printout
• 7. Vision Care Reimbursement Form (168k)
  If you use an outside provider you can submit this form for reimbursement
• 8. UCS and Local Government Legal Claim Form (877k)
  Legal Services Voucher used by UCS and Local Government Members
• 9. Hearing Aid Claim Form (206k)
  Form that needs to be completed to apply for hearing aids.
• 10. Recurring Payment Form (318k)
  Form used for authorization of recurring payment of your benefits
• 11. Local Government Maternity Claim Form (209k)
  Form used to apply for maternity benefit for Local Government Employees.
• 12. HIPAA Release Form (877k)
  Form Required by the Privacy Regulations Promulgated Pursuant to the Health Insurance Portability and Accountability Act of 1996
• 13. Proof of Dependency (53k)
  Form used to further determine eligibility of a dependent
• 14. Remove Dependent Form (132k)
  Used to delete a dependent spouse or child
• 15. Prescription Drug Co-pay- NYS Liquidation Bureau (215k)
  Note: Must also submit itemized pharmacy printout
• 16. EBF Member Plus Enrollment Form – For Local Government Employees Only (480k)
  Form that is used to enroll in EBF Member Plus Dental or Vision plans.
• 17. Disability Form (137k)
  Used to continue coverage for a dependent over 26 with a disability
• 18. Name Change Form (94k)
  Form to submit a name change
• 19. Change of Address (61k)
  This form is used to submit a change of address.
• 20. Annual Physical Voucher (139k)
  Voucher for annual physical (Town of Southold only)
• 21. UCS Maternity Claim Form (62k)
  Form used to apply for maternity benefits for UCS Employees.