Forms

Health Advocate

Health Advocate Authorization Form


Cancer Screening

Cancer Screening Form


Preferred Group - Dental Claims

Dental Form


NOTE: Only use this form to make a claim when you use a non-participating dentist OR when you initially go to a participating dentist. This form pertains to all NTA, clerical SRP, administrator bargaining units and retirees that have this coverage.


Davis Vision - Vision Claims

Vision Claim Form


NOTE: Only use this form to make a claim when you use a non-participating vision provider. Active SRP's should not use this form, but rather the vision claim form for National Vision Administrators. Active SRP's should not use this form.



ShelterPoint Life & National Vision Administrators (vision plan rider on XMM)

Excess Major Medical Claim Form

NOTE:

1. For active teachers and teaching assistants, the policy number is XGNY 91194 and Employer is Nanuet Teachers Association Benefit Fund.

2. For retired teachers and teaching assistants, the policy number is XGNY 1194 and Employer is Nanuet Teachers Association Benefit Fund.

3. For administrators and SRP's the policy number is XGNY 1133.

ShelterPoint National Vision Administrators Claim Form

ShelterPoint In-Hospital Claim Form (Primary insured benefit only - $50 per night in hospital stay)


Preferred Group - FLEX 125 Spending Account

Flexible Spending Plan Reimbursement Voucher

Flexible Spending Plan Voucher Completion Instructions

Claim Submission Guidelines

Modification to Over The Counter Eligible Expense List for 2011

Eligible Medical Expenses per the IRS

Letter of Medical Necessity

Prepaid Benefits Card Application

Direct Deposit Authorization for FLEX Spending Accounts

NOTE: The FLEX Spending forms are here for your convenience. IT CAN ONLY BE USED IF YOU HAVE SIGNED UP FOR THIS PLAN THROUGH DISTRICT PAYROLL. Please contact The Preferred Group or payroll if you have any questions.


Preferred Group - AFLAC

AFLAC Election Change Form

United Health Care (physician portion of NYSHIP)

United Health Care Claim Form (in state)

United Health Care Claim Form (out of state)


NOTE: Completed claim forms along with the doctor's bill may also be faxed to either of these three numbers: 845-336-7989; 845-336-7747; 845-336-7716


Dependent Student Certification

Dependent Student Form


NOTE: This form must be completed by the college registar to validate full time enrollment and submitted to Preferred Group Plans. Fall semester verification covers 8/1 - 3/31. Spring semester verification covers 1/1 - 8/31.



Three Month Extension of Benefits for College Graduate

Extension Form


NOTE: An unmarried dependent student, nineteen years of age or older, but under twenty-five, who graduates from an accredited secondary or preparatory school, college or other educational institution, may continue coverage for up to three months following the end of the month in which course requirements for graduation are completed. There is no extra cost for the extended coverage period but family coverage must be continued for three months. After the three month extension, the graduating dependent will be eligible for the full thirty-six months of COBRA coverage. You can find additional information by clicking here.