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Medical[udesign_icon_font name=”fa fa-heartbeat” color=”#A3A3A3″]

Dental
Vision
Hearing aid
Prescription Drug

[toggle_content title=”details…”] Medical (22-39)
Dental (48-55)
Vision (74)
Prescription (41-46)
Hearing aid (57)
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Disability [udesign_icon_font name=”fa fa-frown-o” color=”#A3A3A3″]

Short-term
Long-term
Extension of Medical coverage during total disability

[toggle_content title=”details…”] Short-term (59-64)
Long-term (64-65)
Extension of Medical coverage during total disability (68)
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Prescription[udesign_icon_font name=”icon-blind” color=”#A3A3A3″]

Express Scripts
Benefits
Claims & appeals
Limitations & exclusions
[toggle_content title=”details…”] Prescription benefits (41-45)
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General Info

Eligibility
Qualified medical child support orders
Medical leave
Termination

[toggle_content title=”details…”] Eligibility (13)
Change in family status (16)
Qualified medical child support orders (18)
Family/Medical leave (21)
Termination & extension of coverage (20)
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Life Insurance[udesign_icon_font name=”fa fa-users” color=”#A3A3A3″]

Ancillary Death Benefit
Beneficiary Designation
Domestic Partner/Spouse
Individual Policy
[toggle_content title=”details…”] Life insurance (69-73)
Ancillary death benefit (73)
Spouse or domestic partner (72)
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Legal [udesign_icon_font name=”fa fa-gavel” color=”#A3A3A3″]

Medical Licensure
Immigration
Family Matters
Landlord-Tenant Issues
[toggle_content title=”details…”] Legal services provided (8)
How to obtain benefits (6)
Who is eligible (7)
What expenses are covered (12)
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Education[udesign_icon_font name=”fa fa-book” color=”#A3A3A3″]

QI/Patient safety
Training Scholarships
Registration Fees
Travel & Lodging
[toggle_content title=”details…”] $3,000 annual funds for QI/Patient safety educational events (claim form below)
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Other Benefits[udesign_icon_font name=”icon-user-md” color=”#A3A3A3″]

COBRA
Accidental Dismemberment
Professional Education Benefit
[toggle_content title=”details…”] COBRA (99)
Accidental Dismemberment (73)
Professional Education Benefit (76)
[/toggle_content][/vc_column_text][/vc_column][/vc_row] [content_block bg_image=”” max_bg_width=”yes” bg_fixed=”no” bg_position=”center bottom” bg_repeat=”repeat-x” parallax_scroll=”no” bg_color=”#293037″ content_padding=”60px 0 30px” font_color=”#444444″] [one_third]

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Submit paper forms by mail or fax to:
House Staff Benefits Plan
520 Eighth Avenue Suite 1200
New York, NY 10018
Fax: (212) 356-8181
*Denotes fillable online form

[tabs] [tab title=”Enrollment Forms”] Membership Form*
Benefits Change Form*
Domestic Partnership Form (Not all hospitals cover same sex partners. See page 2 to find out if your partner is eligible.)
Opposite-sex Domestic Partnership Form (Wyckoff Heights Medical Center only.)
[/tab] [tab title=”Medical”] Dental Claim Form (out-of-network)
Hearing Aid (out-of-network)
Empire Health Insurance (out-of-network)
Davis Vision (out-of-network)
COBRA (continued health insurance after hospital closure or layoff). If you are electing COBRA for the first time, you must complete the Election Form and Payment Form. If you are changing or updating an existing credit card, complete the Payment Form only.
COBRA Notice Form
COBRA Electronic Payment Form
[/tab] [tab title=”Education”] Professional Education Benefit (PEB) Claim Form* (Bronx Leb, Brookdale & Wyckoff Hospitals only)
Professional Education Benefit (PEB) Claim Form* – St. Barnabas Hospital only
Professional Education Benefit (PEB) Claim Form* – Elmhurst Hospital Center only
QI Training & Education Application Form*
QI Training & Education Reimbursement Form* (For those who have been previously approved for this benefit)
Rosetta Stone Claim Form* – (Bronx Leb, Brookdale, Elmhurst, St. Barnabas & Wyckoff Hospitals only)
[/tab] [tab title=”Disability”] Short-term Disability
Long-term Disability
[/tab] [tab title=”Prescription”] Prescription – Express Scripts (Rx)
[/tab] [tab title=”Life Insurance”] Guardian Life insurance
[/tab] [tab title=”Identity Theft Monitoring & Protection”] ID Theft Solutions of America*
[/tab] [tab title=”Appeal”] Appeal claim* If your claim was denied in whole or any part or if you disagree with the decision made please fill out the appeal claim.[/tab] [/tabs]