When submitting applications for Enrollment please follow the guidelines below:
This SDP Health Application and Attestation Form is for all SDP provided medical and health plans. You may need to contact your union for prescription, dental and vision benefits. Complete all sections in entirety. Visit the Independence Blue Cross site for up to date information on all Independence Blue Cross plans.
Please refer to General Documentation Required section for a list of documents that may need to accompany your completed application. The completed application and documentation, if required, can be faxed in to the Benefits Office at (215) 400-4631 or emailed to email@example.com. Please call (215) 400-4630 to confirm receipt if submitting by fax.
- SDP Health Application and Attestation Form
- Request to Remove a Spouse or Dependent
- Personal Choice Out of Network Claim Form
- Exchange Notice
- PFT & Local 634 Members Vision coverage is provided by your union. If you are enrolled in Keystone medical coverage, you have additional vision coverage through Davis Vision hmo-benefit
- CASA, SPAP and Non-Represented Employees: Vision Rider Program Overview
- Non Participating Provider Reimbursement Form
Dental – CASA, SPAP and Non-Represented Employees ONLY
Prescription Drugs – CASA, SPAP and Non-Represented Employees ONLY:
- Select Drug Plan Overview
- Future Scripts Mail Service Order Form
- Prescription Reimbursement Claim Form
Self- Injectable Prescription Drugs for PFT employees. Select the form corresponding to your prescription. If your prescription is not listed, use the General Direct Ship Request form. More information is available on the Self-Injectables page.
- Viscosupplementation (Hyaluronate Acid Products)
- Xolair (Omalizumab)
- Vivitrol (Naltrexone)
- Stelara (Ustekinumab)
- RSV Synagis Prolia_Xgeva (Denosumab)
- Nucala (Mepolizumab)
- Hydroxyprogesterone Caproate Injection
- General Direct Ship Request Form
- Fasenra (Benralizumab)
- Epi Pen Reimbursement Form
- Botulinum Toxins (Botox, Dysport, Myobloc, Xeomin)
Life Insurance Beneficiary Forms
- BENEFICIARY AFFIDAVIT this form is used if the named beneficiary is deceased. This form must be notarized and is require the life insurance company, The Hartford.
- Life Conversion Form
- Hartford Change of Beneficiary for Active Employees
- Retiree Designation of Beneficiary Form
Flexible Spending Account changes
No forms to complete! for changes contact the Employee Benefits Center at 1-800-307-0230 between 8:30AM – 5:30PM EST Monday through Friday for all questions.
Flu Vaccine Reimbursement Form
403(b) & 457(b)
Wage Continuation (Salary Continuance)
PFT, CASA, Non-Represented, Local 634, District 1201/32 BJ and SPAP employees can only apply for Wage Continuation coverage within 30 days of date of hire or during the annual Open Enrollment period. Forms are only available May 1 through May 31.
First year PFT employees can contact firstname.lastname@example.org for enrollment in their first year.
Name Change/Demographic Change Request
- Demographic-Name-Change-Form to update ore correct name, gender or pre-fix or correct date of birth.
- Marital-Status-Change-Request Use this form to update your voluntary marital status, not your tax filing status. Contact the Payroll Department, email@example.com for tax filing status.
Employees must contact Payroll, firstname.lastname@example.org or 215-400-4490 to request an address change or a change in tax withholding status.
COBRA /RETIREE Coverage forms
How do I change or correct my name on my Social Security number card?
If you legally change your name because of marriage, divorce, court order or any other reason, you must tell Social Security so you can get a corrected card. You cannot apply for a card online. There is no charge for a Social Security card. To get a corrected Social Security card, you will need to:
- Show the required documents. You will need proof of your identity. See Learn What Documents You Need for more information. Under the heading, “Type of Card,” select “Corrected” for a list of the documents you need;
- Fill out and print an Application for a Social Security Card; and
- Mail your application and documents to your local Social Security office.