• Membership Form
• Update Form – To add new dependents to your plan. Requests to add dependents must be received within 30 days of qualifying event (birth/adoption or marriage), and you must attach requested documentation (see form).
• Affidavit – If you cannot locate the marriage certificate or birth certificate(s), you can submit this affidavit in its place. The affidavit must be notarized.
• Domestic Partnership Application (only same-sex partners eligible) – To add a partner, download an application and return a notarized copy, along with all requested documentation, to the Plan office. You must also complete an Update Form above.
• Opt-Out Benefits Form – Please fill out this form if you would like to remove yourself and/or your dependent(s) from the CIR Benefits Plan.

• Empire Machine Readable Files
• Empire Health Insurance Claim Form (out-of-network)
• Empire’s website
• Summary of Benefits and Coverage (“SBC”) PPO
• Summary of Benefits and Coverage (“SBC”) POS
• Live Health Online
  • Instant access from your phone or computer
  • Care and coverage for COVID-19
  • Medical FAQ
  • Psych FAQ
  • MyStrength: Mental Health
• Building Healthy Families and Gift Card Details
• The Autism Program
• WINFertility program and WIN app demo video
  • Any services rendered prior to January 1, 2022 will not be covered.
• Travel Insurance

For purposes of our disability benefits, “disabled” means you can no longer perform the duties of your occupation due to accidental bodily injury, sickness, or a related medical condition, including pregnancy or childbirth. You must also be under the care of a licensed provider as defined by the state in which you work.

• Short-term Disability Claim Form
  • If this is your first full-time job, you would have to work four consecutive weeks in order to become eligible for short-term disability. If this isn’t your first full-time job, you will be eligible for short-term disability payments on your first day of employment, unless you worked less than four weeks in previous job.
  • Coverage begins on the eighth (8th) day of your disability. The maximum benefit payable is 60% of your weekly salary, up to $692 per week, for up to 26 weeks. See the Summary Plan Description (SPD) for more details.
  • If you are going out on a disability leave, contact your employer as soon as possible.
  • Please mail or fax the STD disability claims to: Standard Security Life Ins, P.O. Box 25339, Farmington, NY 14425. Fax: (585) 398-2854.
• Paid Family Leave (PFL) Claim Form – Administered by Standard Security Life Insurance Company of New York
  • PFL provides wage replacement and job security for three leave types:
    1. Bonding with a child during the first year after birth, or during the first year after placement of an adopted or foster child.
    2. Caring for a close family member with a serious health condition.
    3. A qualifying military event is when a spouse, child, domestic partner, or parent of the employee is on active duty or has been notified of an impending call or order of active duty.
  • Coverage includes a maximum weekly payout of $1,151.16 a week for a maximum 12 Weeks.
  • Visit www.sslicny.com and click on “I’m a Claimant” to find the New York State PFL Claim Form.
  • Paid Family Leave FAQs
• Long-term Disability Claim Form
  • The LTD plan pays you 60% of your monthly salary, up to a maximum of $3,500 per month. LTD benefits typically start if you are still disabled after 26 continuous weeks. For detailed information on Long-Term Disability see the Guardian Certificate.
  • When you terminate employment, you will have the option to convert this benefit to an individual policy, subject to certain conditions.
• INSMED Portable Disability Coverage – Policies offered to you without any medical underwriting requirements or exams.

Guardian Life Insurance:

• If you die, a death benefit of $125,000 benefit will be paid to any beneficiary you name. You will receive a $20,000 death benefit if your spouse or domestic partner dies.
• For instructions on submitting a Group Life Claim, click here.
• When you terminate employment, you will have the option to continue the life insurance coverage as either group term insurance (this is called “porting” and is similar to how you have been covered during training) or you may convert this benefit to an individual policy, subject to certain conditions.
• Whether you decide to port or convert, the availability and pricing of this coverage does not depend on any past or current medical conditions.
• You have up to 31 days from your date of termination to submit one of these forms directly to Guardian: For an overview of the differences between porting and converting, click here.
  • Life Insurance Portability Form
  • Life Insurance Conversion Form

Participants are eligible for up to $3,000 in reimbursement per plan year (July 1-June 30) to cover expenses related to attend a U.S. patient safety event. You must submit at least 6 weeks prior to the conference date.

• QI Training & Education Application Form
• QI Training & Education Reimbursement Form (For those who have been previously approved for this benefit)

What is COBRA continuation coverage?

COBRA continuation coverage allows you to choose to continue and pay for group health benefits provided by CIR for up to 18 months after your termination date.

Who is eligible?

You and your dependents covered under the Plan on the day before you terminated from your employer.
You will receive a COBRA notice mailed to the address we have on file. This notice has important information about your rights related to continued health care coverage in the Voluntary House Staff Benefits Plan.

COBRA Election forms:

To apply for COBRA, you will need to complete the Election form that corresponds to the Dental Plan you had prior to termination. If you don’t remember which Dental Plan you have, look at your Dental ID card. Here is a sample of what the Managed Dental Guard ID card looks like:

Your Cobra Election includes the following benefits: Medical, RX, Vision, and Dental. The only difference in the benefits is the Dental option you had prior to termination. Please select the Election form (also includes the COBRA Credit Card Authorization Form) that applies to you:

DentalGuard Preferred (DGP)

• Individual DGP: COBRA Notice / Election & Payment Form
• Family DGP: COBRA Notice / Election & Payment Form

Managed DentalGuard Preferred (MDG)

• Individual MDG: COBRA Notice / Election & Payment Form
• Family MDG: COBRA Notice / Election & Payment Form

You have up to 31 days from your date of termination to submit one of these forms directly to Guardian:

• Portable Disability Insurance
• Portable Life Insurance – View the Life Insurance tab for more information.

• Appeal Claim Form – Complete this form if your claim was denied in whole or any part or if you disagree with the decision that was made.
• Claim Reprocess Form – Complete this form if your claim was denied and you are able to provide additional information.