• Membership Form
• Domestic Partnership Application (both same-sex and opposite-sex partners are 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 below.
• 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.
• 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.
• 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.

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.

• Disabled Health Premium Reimbursement
• Short-Term Disability (STD) Benefits Claim Form
  • Coverage begins on the eighth (8th) day of your disability. The maximum benefit payable is 70% of your weekly salary, up to $875 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.
• Long-Term Disability (LTD) Benefits Claim Form
  • The LTD plan pays you $3500 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.
• Rivetti Financial Disability Coverage
  • As a resident, you are eligible to apply for Specialty Specific disability insurance at discounted rates. There is also no medical screening required to qualify. You are only eligible for this plan during your residency, so act now and don’t wait.

• Professional Educational Benefit (PEB) Claim Form – Now available through the Member Portal – reimburses costs associated with books, board exams, medical licensure fees, dues, subscription, journals and mobile electronic medical devices. Items that can be used for both personal/non-work purposes AND work/training purposes are NOT eligible for reimbursement, such as:
  • Accessories
  • Calling and/or Service Plans
  • Cameras
  • Desktop Cameras
  • Data Service Plans
  • eBook Readers
  • Insurance
  • Software (e.g., Excel, Word, PowerPoint)
  • Upgrade Fees
• QI Benefit – 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
  • QI Training & Education Reimbursement Form (For those who have been previously approved for this benefit)
• Opportunity to learn a new language with Rosetta Stone

Rivetti Financial offers Student Loan Consultations to CIR members at a discounted rate:

• Receive individualized advice regarding your student loans
• Complete analysis of your federal and private loans
• Analysis of different repayment plans (Standard, IBR, PAYE, REPAYE)
• Assistance selecting appropriate repayment plan
• Projections of future payments and forgiveness
• Eligibility for Public Service Loan Forgiveness (PSLF)
• Refinancing suitability analysis
• Introductions to competitive refinancing lenders

How to sign up:

1. Verify your CIR membership to receive the discount code
2. Go to the registration form
3. Complete the registration form and upload your documents
4. Schedule a date and time
5. Pay the discounted consulting fee

Once the registration is complete, we will analyze your loans and request any additional information or documents from you if necessary. We will call you on the day and time of your consultation to conduct a review of your student loans with you.

Consultations are conducted either by phone or through computer screen sharing if you are a visual learner (similar to a webinar).

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 House Staff Benefits Plan.

COBRA Election forms:

Your COBRA Election includes Vision and Supplemental Major Medical and Dental. Please select the Election form (also includes the COBRA Credit Card Authorization Form) that applies to you:

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

You have up to 31 days from your date of termination to apply for continued disability coverage with Rivetti:

• Disability Insurance

Now available through the Member Portal

As you start your residency program with LAC + USC Medical Center, please be aware that there is a 90-day waiting period after you start your employment before your employer-sponsored healthcare coverage begins.

Your employer-sponsored healthcare coverage will start at the beginning of September if you enroll during your orientation in June or July.

 You can purchase healthcare coverage for the gap period

• If you purchase COBRA coverage from your former insurance carrier or a form of GAP coverage to cover yourself and/or your family during this 90-day waiting period, the CIR/SEIU House Staff Benefits Plan will reimburse you up to $500 for the 90-day window that you did not have LAC + USC Medical Center employer-sponsored healthcare coverage.
• In order to receive the reimbursement, you will need to fill out the LA GAP Insurance Claim Form and provide:

1.  A copy of the COBRA notice and proof of COBRA coverage payment, or
2. The GAP policy statement, and a copy of the GAP policy payment receipt.

• 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.