Benefits Fund participants may download PHI Authorization and Physician Nomination forms below then simply fill out and sign your paperwork, take a picture, and email it to benefitsdepartment@rnbenefits.org. Disability forms may be emailed to disability@rnbenefits.org. All other forms, including Enrollment forms, should be mailed to the address specified on the form. Photos are not accepted for Enrollment forms.
Medical, Dental, Rx, Vision
Aetna Claim Form
Dental care Claim Form
Anthem BlueCross BlueShield Claim Form
Submit a medical claim under Anthem
Anthem BlueCross BlueShield Transition of Care Form
Request transition of medical care from an out-of-network provider
Davis Vision Claim Form
Vision Care form
Express Scripts Home Delivery Order Form
Rx mail-order forms for maintenance meds
Express Scripts Prescription Drug Reimbursement Form
Reimbursement for Prescription Drugs
Gym Reimbursement Program
Reimbursement for health club/gym membership
PHI Authorization
Authorization form for the Disclosure of personal health information
Disability Forms
MetLife Attending Physician Statement
Attending physician’s statement of continued disability
MetLife Short-term Claim
Notice and proof of claim for short-term disability benefits
MetLife Authorization
Authorization form for the disclosure of personal health information
MetLife EFT Authorization
Authorization of direct deposit of disability payment
MetLife Psychiatric Questionnaire
Attending physician’s statement of continued disability for mental health
Eligibility Forms
Young Adult Form
Dependents ages 26 through 29 are eligible for medical insurance only
Enrollment Form
Used to enroll in the Benefits Fund. (You must mail or fax this form. Photos are not accepted.)
Opt Out Application
As outlined in your CBA, you may be able to waive Benefits Fund health coverage as long as you have coverage through another health plan
Open Enrollment Form 2025
The open enrollment period for Benefits Fund participants and their dependents runs from November 1, 2025 through December 31, 2025 effective January 1, 2026.
