Reimbursement and Claim Forms
Prescription Drug Benefit Claim Form & Instructions

Prescription Drug Co-payment Reimbursement form plus guideline for submitting request for payment.
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Non-Participating Optical Reimbursement Form

Non-Participating Optical reimbursement form plus guideline for submitting request for payment.
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Hospital Reimbursement Form


Please use this form for all Hospitalization claims.
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Corrective Eye Surgery Reimbursement

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Hearing Aid Reimbursement Form

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Dental Claim Form

NYS Court Clerks Dental Form for active and retirees.

Click here to download