PAID FAMILY LEAVE APPLICATIONS
(Click on form needed, will take you to website of correct forms)
SCROLL DOWN TO BOTTOM OF WEBSITE FOR THE SPECIFIC PAID FAMILY LEAVE FORMS:
Care for a Family Member with Serious Health Condition
Assist Families in Connection with a Military Deployment
COBRA Model Sample Letter for New York State Excellus Healthy New York Employee Enrollment Form Excellus Healthy New York Employer ENROLLMENT PACKET - (New Groups) Excellus EFT Automatic Payment Individual Plans Excellus Blue Cross HIPAA Release Form Excellus Blue Cross Subscriber Medical Claim Form
Excellus Prescription Drug Claim Form 2020.pdfg Form Excellus Blue Cross Waiver of Group Coverage
EPIC APPLICATION Form EPIC 2020 Program Highlights Healthy NY: Healthy NY Application for Small Business Medicare Part - B Enrollment Form Medicare Employer Statement Scope of Appointment MVP: MVP Small Group Enrollment Form MVP Waiver of Coverage Form ShelterPoint NYS Disability Benefits Application ShelterPoint NYS Disability Claim Form
Paid Family Leave for yourself due to COVID - 19 quarantine/Isolation
Request for COVID-19 Quarantine PFL – Child United Concordia Group Dental Application (for Employer) United Concordia Employee Dental Enrollment Form Univera Healthy New YorkEmployee Enrollment Form