Forms

• Active Beneficiary Enrollment Card

• Anesthesia Claim Form - Surgical

• Anesthesia Claim From - Maternity

• Attestation of Domestic Partner Status

• Change of Address

• GVS Optical Reimbursement Form

• Health Benefits Application

• NYC Offered Health Plans

• Attestation of Domestic Partner Status

• Change of Address Form

• GVS Optical Reimbursement Form

• NYC Fire Pension Fund Change of Address Form

• NYC Fire Pension Fund Check Affidavit

• NYC Fire Pension Fund Electronic Fund Transfer Form

• NYC Fire Pension Fund - Life Insurance Fund Beneficiary Form

• NYC Fire Pension Fund W-4P Form

• NYC Offered Health Plans

• Medicare Part B Reimbursement Application

  • For more information regarding Medicare Part B, please visit: https://www1.nyc.gov/site/olr/health/retiree/health-retiree-medb-irmaa.page

• Retired Beneficiary Enrollment Card

• Summary of Benefits

• EmblemHealth City of NY MLC At Home COVID 19 Test Claim Form

• EmblemHealth City of NY MLC At Home Rapid COVID-19 Testing Claim Form Instructions and Info

• IRMAA Reimbursement Form

  • For more information on IRMAA Reimbursements, visit: https://www1.nyc.gov/site/olr/health/retiree/health-retiree-medb-irmaa.page

• Surgical Assistance Fund Fee Rates

• Surgical Assistance Fund Info and Application

• Surgical Assistance Fund Summary of Benefits

• FDNY Line-of-Duty (LODI) Prescription Benefit Plan

• FDNY World Trade Center Health Program - WTC Prescription Plan Update Fact Sheet

• What's In Your Wallet? Prescription Card Fact Sheet

• MetLife Dental Benefits 

• MetLife Video for UFA Members 

• MetLife Dental Benefits - Effective Jan 2024 

• MetLife & UFA

• MetLife December 2023 Update 

• MetLife Preferred Dentist Program (PDP)

  • Those currently enrolled in the UFA Dental plan will be in the MetLife PDP plan effective 1/1/24.

  • PDP FAQS 

  • Out of Network Claim Form

• MetLife Managed Care Plan (HMO)

  • Those currently enrolled in Dentcare will be in the MetLife HMO/Managed Care Plan effective 1/1/24.

  • HMO/Managed Care FAQs 

• After the January 2024 MetLife rollover, there will be two changeover periods in April and October 2024 for those members wishing to switch plans.

• Change of Address Checklist

• Divorce Checklist

• Domestic Partnership Checklist

• New Baby Checklist (Active and Retired)

• Newly Wed Checklist (Active and Retired)

• Retirement Checklist

• COBRA Package

• I.T.H.P. Waiver

• NYC Fire Pension Fund Change of Address

• NYC Fire Pension Fund Electronic Funds Transfer

• NYC Fire Pension Fund Manual

• NYC Fire Pension Fund Retirement Checklist

• NYC Fire Pension Fund Telephone Directory

• Service Retirement Application

• Tier III Vesting Info

• Tier II Vesting Info

• Vested Application