Reimbursement and Claim Forms

*NOTE MEMBER'S NAME IS ALSO NECESSARY IN DEPENDANT CLAIMS*

Prescription Drug Benefit Claim Form & Instructions

Prescription Drug Co-payment Reimbursement form plus guideline for submitting request for payment.




Non-Participating Optical Reimbursement Form

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




Hospital Reimbursement Form


Please use this form for all Hospitalization claims.




Corrective Eye Surgery Reimbursement




Hearing Aid Reimbursement Form




Dental Claim Form

NYS Court Clerks Dental Form for active and retirees.