This is where header code goes

Health Forms

Enrollment Forms

CIGNA Dependent Coverage Form

Use this form to enroll eligible dependents for Medical/Hospital/Pharmacy and Vision coverage (coverage for you only, as an employee, does not require the completion of a form). A separate dependent form will need to be completed for dependent coverage under either of the CIGNA Dental Plans. See the CIGNA Self-Pay Dental Informational page for specific details.

CIGNA Dental Enrollment Form

HIP an Emblem Health Company (NY) Enrollment Form

Kaiser DC Enrollment Form

Kaiser NoCA Enrollment Form

Kaiser SoCA Enrollment Form


Claim Forms

CIGNA Health Claim Form Use this form to get reimbursed for Medical/Hospital claims that were incurred from out-of-network providers. (In-network providers will bill CIGNA Dental directly)

CIGNA Prescription Claim Form Use this form to submit a claim for CIGNA Prescriptions. (if you use a network pharmacy the pharmacy can submit the claim on your behalf)

Dental Out of Network Claim Form Use this form to get reimbursed for Dental PPO claims that were incurred from out-of-network providers. In-network providers will bill CIGNA Dental directly. (your dentist files claims for covered services under the DHMO)

Davis Vision Out of Network Claim Form Use this form to get reimbursed for Vision claims that were incurred from out-of-network providers. In-network providers will bill Davis Vision directly.


Domestic Partners Affidavit For Health Fund

Applying for Health Coverage for your domestic partner

1) When applying for Dependent Coverage for a Domestic Partner during one of the qualifying events, the participant must contact the Funds Office for verification of the qualifying event and the appropriate premium that must accompany the application.

2) The participant must complete and NOTARIZE the forms labeled “Equity-League Pension and Health Fund Affidavit of Domestic Partnership” and “Attachment 1, Declaration of Financial Interdependence.” Please note that if the state or municipality in which you reside provides for the registering of Domestic Partners, you must register with such state or municipality and also attach a copy of the registration to the Domestic Partner Affidavit.

If you submit proof of Domestic Partner registration or a certificate of marriage (from a jurisdiction legalizing same-sex marriage), you do not need to submit the Declaration of Financial Interdependence or further proof of financial interdependence.

3) Please mail the competed forms and premium to:

Equity League Health Trust Fund 165 West 46 St, 14 th Floor New York, NY 10036.

4) The Equity-League Funds Office will process your application. If additional information is required in order to process your request, the Equity-League Funds Office will contact you.

EQUITY-LEAGUE HEALTH FUND DOMESTIC PARTNER COVERAGE

1. Definition of Domestic Partners

Equity-League Health Fund defines domestic partners as follows: Two adults (both of whom are 18 years or older) of the same or opposite sex, neither of whom is married (to anyone other than the domestic partner)* or

a) either:

i) resided with each other for six months prior to the application for benefits and who intend to live continuously with each other indefinitely, or

ii) were legally married in a state or country legalizing same-sex marriage;

b) are not related by blood closer than the law would permit by marriage;

c) are financially dependent on each other;

d) have an exclusive close and committed relationship with each other; e) have not terminated the domestic partnership; and f) if eligible under (a)(i) above, and living in a state or municipality providing for the registration of domestic partnerships, have registered as domestic partners.

* You are still considered married even if you are legally separated

2. Procedure for Verifying Domestic Partner Status

A participant who seeks domestic partner coverage is required to submit an affidavit attesting to the domestic partner status and a declaration of financial interdependence with two items of proof (such as joint lease or mortgage, joint bank account). (A sample affidavit and declaration is attached).

Persons who fraudulently, wrongfully (or negligently) obtain coverage for persons who are not entitled to such coverage, or who fail to timely notify the Plan Administrator of the termination of a domestic partnership, may be subject to disciplinary and/or civil action. You will be required to refund the Fund Office for the costs associated with the wrongfully extended coverage.

In addition, those who live in states or municipalities offering a domestic partner registry (such as California and New York City) will be required to show proof that they have registered as domestic partners.

3. Domestic Partner Coverage

Domestic Partners of participants would be eligible for self-pay health coverage on the same basis as current dependent coverage.

4. Modification and Interpretation

The Trustees reserve the right to amend or modify the eligibility requirements for domestic partner coverage and to amend, modify or terminate domestic partner coverage at any time for any reason. The Trustees reserve the right to interpret all plan documents concerning domestic partner coverage and to interpret the requirements for and extent of such coverage.

Domestic Partners Affidavit Form For Health Fund

Declaration of Financial Interdependence For Health Fund

NY COBRA Subsidy Program

New York State COBRA Assistance Subsidy Payment Program

The New York State Legislature has adopted a law to provide a subsidy to New York State residents in the entertainment industry whose current income is below a certain threshold. If you are eligible for COBRA, and are a New York State resident, then you may be eligible for a subsidy to defray 50% of the cost of those COBRA premiums.

There are certain conditions that MUST be met in order for you to qualify for this program. The application, and listing of instructions from The New York State Insurance Department explains the conditions of the program and how to apply.

Once completed, all applications should be sent to the New York State Insurance Department AS SOON AS POSSIBLE. Once applications have been approved, and accepted, members are eligible to receive up to total of 12 months of premium assistance. (there is a 12 month lifetime subsidy limit regardless of the number of times you qualify for COBRA)

Each time you apply for COBRA, and require financial assistance through this program, you must re-apply, and send a new application to the New York State Insurance Department. For example, let’s say that you are receiving health coverage through COBRA for 3 months from January 1 through March 31, and qualify for the COBRA Subsidy Program. You then become eligible for health coverage through covered employment effective April 1 for 6 months. You will be covered until September 30, and the program will not be in effect during this period. If you do not re-qualify for coverage when the 6 months expires, you will be given the option to continue your coverage through COBRA that would begin on October 1. At that point, you will have to send another application to the New York State Insurance Department to see if you would qualify for the assistance program again.

Once the Fund Office receives notification from the State Insurance Department that your application has been approved, you will be entitled to a refund of 50% of the COBRA premium you had paid in full. Therefore, you should submit your application to the State Insurance Department as soon as possible. For any month for which the premium has been paid in full and the Fund then receives 50% from the State, you will, of course, receive a refund of the credit. But the State of New York will not approve payments retroactively, so the application should be submitted as early as possible.

In determining whether you are eligible for a COBRA subsidy, the State Insurance Department applies monthly household income tests.  Therefore, you must submit your income information from the current gross monthly income and from the previous full calendar month. Therefore, you may be eligible even if your earnings were substantial during the previous year.

The Fund will mail New York State residents the required application with the COBRA packets each time that a member’s health coverage through covered employment becomes terminated.  Please be aware that members residing in New Jersey and Connecticut, DO NOT qualify for this program.  If you have any questions about this program you may contact the Consumer Services Bureau of the State Insurance Department at 1-800-342-3736 or the Actors Fund at (212) 221-7301.


HIPAA Forms

Health Insurance Portability and Accountability Act

Appointment of Personal Representative Form

Use this form to authorize a personal representative to act for you in receiving any information provided to you as a participant/beneficiary of the Plan.

Request That PHI Be Transmitted Confidentially by Alternate Means

Use this form to authorize different address or manner or place where an individual will receive PHI (Protected Health Information).

HIPAA Complaint Form

Use this form to submit a complaint, such as perceiving an employee violating the privacy policies and procedures.

Request for Access to PHI Form

Use this form to request to inspect and copy specified PHI (Protected Health Information).

Request for Restrictions on Use & Disclosure

Use this form to request that use and access to PHI (Protected Health Information) be restricted in a specified manner.

Request for Accounting of Disclosure of PHI

Use this form to request an accounting of the disclosures of PHI (Protected Health Information).

Please mail the completed forms to:

Equity-League Health Trust Fund 165 W 46 St, 14th Floor New York, NY 10036.