• NY State Employees
  • State Benefits
  • Enroll Online
  • Download Forms
  • Plan Brochure
    • State Plan Booklet (pdf)
• Local Gov't Employees
  • Vision Benefits
  • Dental Benefits
  • EBF Member Plus Plan
  • Enroll Online
  • Download Forms
  • Plan Brochures
• UCS Employees
  • UCS Employee Benefits
  • Enroll Online
  • UCS Booklet (pdf)
  • UCS Retiree Booklet (pdf)
  • Vision Claim Form (pdf)
  • Legal Services Claim Form (pdf)
  • Maternity Claim Form (pdf)
  • RX/Physician Combined Co-pay Claim Form (pdf)
  • Hearing Aid Claim Form (pdf)
• Retiree Benefits
• Reimbursed Benefits
  • Reimbursed Benefits Info
  • Hearing Aid Form (pdf)
  • Legal Plan Form (pdf)
  • Maternity Plan Form (pdf)
  • RX Co-Pay Form (Local) (pdf)
  • RX Co-Pay Form (State) (pdf)
  • RX Co-Pay Form (UCS) (pdf)
  • Physician Co-Pay Form (pdf)
• Benefit Specialists
  • Benefit Specialists Info
  • Region 1 - Candace Sclafani
  • Region 3 - Gina Tralongo
  • Region 4 - Erin Bazinet
  • Region 5 - Andrew Miller
  • Region 6 - Courtney Sim
  • NY State - Shane Rapping
  • NY State - Kylie Chard
• Negotiator's Guide
• Dental Provider Portal
• Benefit Admin Portal
  • NY State HBA
  • Local Government BA

Popular CSEA EBF Forms

 

 

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Current Forms Available

• 1. Universal Enrollment Form (70k)
  The CSEA EBF Enrollment Form has been recently updated
• 2. 2022 Prescription Drug Co-Pay (for NYS Employees) (64k)
  Note: Must also submit itemized pharmacy printout
• 3. Recurring Payment Form (318k)
  Form used for authorization of recurring payment of your benefits
• 4. 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.
• 5. Disability Form (137k)
  Used to continue coverage for a dependent over 26 with a disability
• 6. UCS and Local Government Legal Claim Form (877k)
  Legal Services Voucher used by UCS and Local Government Members
• 7. Prescription Drug Co-pay- NYS Liquidation Bureau (215k)
  Note: Must also submit itemized pharmacy printout
• 8. Proof of Dependency (53k)
  Used to provide proof of dependency for children under age 19
• 9. Remove Dependent Form (132k)
  Used to delete a dependent spouse or child
• 10. Local Government Co-Pay Claim Form (196k)
  Note: Must also submit itemized pharmacy printout
• 11. Vision Care Reimbursement Form (168k)
  If you use an outside provider you can submit this form for reimbursement
• 12. HIPAA Release Form (877k)
  Form Required by the Privacy Regulations Promulgated Pursuant to the Health Insurance Portability and Accountability Act of 1996
• 13. Hearing Aid Claim Form (206k)
  Form that needs to be completed to apply for hearing aids.
• 14. Maternity Claim Form (209k)
  Form that is used to apply for maternity benefit.
• 15. EBF Member Plus Enrollment Form (480k)
  Form that is used to enroll in EBF Member Plus Dental or Vision plans.
• 16. Annual Physical Voucher (139k)
  Voucher for annual physical (Town of Southold only)
• 17. Name Change Form (94k)
  Form to submit a name change
• 18. Change of Address (61k)
  This form is used to submit a change of address.
• 19. UCS Full Time & Retiree Co-Pay Form (59kb)
  UCS Full Time & Retiree Co-Pay Form

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