NYC Nurse-Family Partnership If you’re a service provider, you can learn more on the NYC Health website, and you can refer eligible patients/clients by filling out our referral form and faxing it to 347-396-4360 or emailing it to nycnfp@health.nyc.gov. Payroll Forms. Service Compensation Form E745; Termination Pay Form E745; Final Entitlement - UFT Paraprofessional; Retirement Systems. A number of retirement systems service employees of the Department of Education (DOE). Please see the family site for all updates on Immunization Exceptions. Click “sign in.” NOTE: Your Network/e-mail ID is the ID you use to access your DOE e-mail (e.g., If your DOE e-mail is JDOE@schools.nyc.gov then your network/e-mail ID is JDOE.) Medicare Request for Employer Information Form. Health Benefits Summary Plan Description (SPD) Health Benefits Application/Change Form (Not for use by NYCAPS Agencies) Health Plan Rate Chart for Employees. Attach any additional documentation to this form. The New York State Department of Labor is a major arm of state government. 2021 All Rights Reserved, NYC is a trademark and service mark of the City of New York, Responsibilities & Health Benefits Assistance, COBRA Form, Notice of Rights and COBRA Rates, Young Adult Option, Through Age 29, (NYS Law Chapter 240). This will only delay processing. New York State Department of Labor Telephone Claims Center (888) 209 – 8124. 3) For questions regarding the PICA prescription drug benefit program please call 1-800-467-2006. 8����g���jU�m�Cp�lԄ�8��r���Cp8��TM�p��dV�or��<15�9�����c�y}��ߚ�Λ뜣v���K��9��M�135�l8�Η-v��Ϭ'I6��u9S�e5�.W��`�߉���.�1�%���0����}@g�Y���㞣��� ��̭�NF8���rhSX߁ޖ��W��@���Wy�'`]��$�����3�v��. DOE Employees Your User name is your DOE email without @schools.nyc.gov. You can also use it to take advantage of local incentives and discounts available to DOE employees. decline this benefit, by obtaining a Medical Spending Conversion Form, both of which are obtainable at my payroll office. If I have checked the Waive Benefits Box in Section A, I am choosing not to participate in the City Health Benefits Program at this time. New York City Employees' Retirement System. Due to the closure of the office, if you mailed or faxed forms or correspondence March 11, 2020 or after, we cannot access or process that form. Please identify yourself as a City of New York retiree or dependent of a retiree. As a reminder, all employee HR forms can be found at the HR Connect Web Portal. School physicians and nurses conduct physical exams and help manage the health of students with health issues like asthma, allergies and diabetes. For all other members enrolled in a HMO plan, please contact your health plan at the customer service numbers on the back of your ID card. Menu Search. CHILD & ADOLESCENT HEALTH EXAMINATION FORM NYC DEPARTMENT OF HEALTH & MENTAL HYGIENE — DEPARTMENT OF EDUCATION Please Print Clearly NYC ID (OSIS) TO BE COMPLETED BY THE PARENT OR GUARDIAN Child’s Last Name First Name Middle Name Sex M Female M Male The comparison chart of New York City health plans provided by the Welfare Fund allows you to compare the various options for in-service members and retired members not eligible for Medicare and for retired members who are on Medicare. Health Benefits Summary Plan Description (SPD), Health Benefits Application/Change Form (Not for use by NYCAPS Agencies), COBRA Form, Notice of Rights and COBRA Rates - January 2021, COBRA Form, Notice of Rights and COBRA Rates - July 2020, Dependent Eligibility Required Documentation, Young Adult Option, Through Age 29, (NYS Law Chapter 240) - January 2021, Young Adult Option, Through Age 29, (NYS Law Chapter 240) - July 2020, Case Management Program (for GHI-CBP/EBCBS Members), Creditable Coverage Notice (Employees Age 65 or Over), Form 1054 (For Use By Authorized Personnel Only), Health Insurance Marketplace (Exchange) Notice, List of Services Requiring Pre-Certification. Compare health plans. (Section 125 does not apply to retirees.) h��1KA��&��B�,N�BI)���B� ����(����`ka#�"�+����B����Bo� �s��RX\��x�}�;�9v�r�D�5�s'�~BO�O�28�� REQUIRED NYS SCHOOL HEALTH EXAMINATION FORM TO BE COMPLETED IN ENTIRETY BY PRIVATE HEALTH CARE PROVIDER OR SCHOOL MEDICAL DIRECTOR Note: NYSED requires a physical exam for new entrants and students in Grades Pre-K or K, 1, 3, 5, 7, 9 & 11 ; annually for Your file has been received" upon completion of your document upload. Left and right arrows move across top level links and expand / close menus in sub levels. Alert: Beginning Tuesday, July 7, 2020, the service window for the New York City Office of the Comptroller located at 1 Centre Street, New York, New York 10007 will be open on Tuesdays, Wednesdays, and Thursdays from 10 AM to 1 PM. Return completed forms to your school’s 504 Coordinator. Health Benefits Forms & Downloads. The health and safety of all of our employees and partners is our first priority. Due to increased volume, you may experience longer wait times, and voice mails may be returned after hours. To obtain a DOE Photo ID card, complete the Application Form for NYC DOE Photo ID Card. Please resubmit your documents as follows: 1) Forms and documents can be submitted electronically using the following link: https://nycemployeebenefits.leapfile.net. Congratulations on being considered for employment with the New York City Department of Health and Mental Hygiene! Learn about New York City Department of Education Health Insurance, including a description from the employer, and comments and ratings provided anonymously by current and former New York City Department of Education employees. DIVISION OF HUMAN CAPITAL - HR CONNECT MEDICAL, LEAVES AND RECORDS ADMINISTRATION 65 Court Street, Brooklyn, NY 11201 . Any medication or medical treatment forms will go to the school nurse/medical professional in the building. Conditional Offer of Employment Medical Form; DOI Checklist; Personal and Tax Data Changes. Please go here for videos and other information on how to apply for health benefits as a retiree, be reimbursed for Medicare Part B, and more. Health benefits are not offered or administered by NYCERS. Form 1095-C is a tax form under the Affordable Care Act ("ACA") which contains information about your health care insurance coverage. You can also view the Frequently Asked Questions About Legislation Removing Non-Medical Exemptions from School Vaccination Requirements from New York State Department of Health; Parent Letters, Policy Change, for Warnings and Exclusions . Sections A, B & C: Check off the reason for submission of this form. See below to access your retirement website. City of New York. Your request will be returned unfulfilled if employee authorization is not provided. This health screening must be completed on each day of arrival and results will reset at midnight of each day. COBRA Form, Notice of Rights and COBRA Rates - January 2021. Go to OLR’s Health Benefits Program page. Pre-Employment Background Checks. Glassdoor is your resource for information about the Health Insurance benefits at New York City Department of Education. Employees may only transfer plans during a transfer period or upon a change of residence outside/inside of the service area of the health plan. ADDITIONAL MEDICAL DOCUMENTATION AND/OR EXAMINATION Privacy Policy. Forms for Filing an Appeal to the Commissioner Involving Homeless Children and Youth Please check our website periodically for updates. Left and right arrows move across top level links and expand / close menus in sub levels. Sample Forms for Filing an Appeal for Petitioners not Represented by an Attorney 2. Also, please do not send forms or documents via express mail. Enter the appropriate information as follows: Network/e-mail ID, Password and choose and enter your SS, EIS ID or Employee ID. Please do not submit your form/document more than once. Form 1095-C is distributed to all full-time employees working an average of 30 hours or more per week, for all or part of the calendar year. For Educational Accommodations, the 504 Coordinator will contact you to schedule a meeting within 30 days of your initial request. New Hire Processing Forms. Call Center Hours Monday-Friday, 8 am – 5 pm The site navigation utilizes arrow, enter, escape, and space bar key commands. New York City schools offer many health services to support student health. Testing is being prioritized for all DOE students (3K through 12th Grade), employees, employees of DOE contracted early childhood programs, and affiliated family child care networks, and employees of DOE- and DYCD-contracted Learning Bridges programs at 22 … Department of Education, HR Connect Medical Administration Office, 65 Court Street, Room 201, Brooklyn, New York 11201, Att: Accommodation Unit. For detailed instructions on how to submit your form/document securely through LeapFile and to view a short video, click here. Check the EMPLOYEE box at the top of the form. It administers the State Labor Law and related laws, rules and regulations. %PDF-1.6 %���� Information regarding your city health plan coverage can be found on the city's website. 1044 0 obj <> endobj Call Center (347-643-3000) is open Monday through Friday, 8 am to 5 pm, to answer questions and schedule consultations.Telephone and video consultations are available to maximize your health and safety. Medical documentation to support the request must be attached. The Health Benefits Retiree client service walk-in center is closed. 1277 0 obj <>/Filter/FlateDecode/ID[<68E2935CB6395D4B90C02C4F0FE51EF9>]/Index[1044 460]/Info 1043 0 R/Length 390/Prev 407817/Root 1045 0 R/Size 1504/Type/XRef/W[1 3 1]>>stream Sign in to get information related directly to your plan and to get plan-related updates including checking claim status and requesting ID cards. Referral form with instructions English. TO BE COMPLETED AND SIGNED BY EMPLOYEE: Employee's First Name Home Address Work Location Borough Location … Accommodation Request Form on page #2. You will not receive a separate email confirmation. The request is to be forwarded to the N.Y.C. Premiums paid by the City during the period of unpaid leave may be recovered if the employee fails to return to work. To keep everyone safe as the COVID-19/coronavirus situation continues to develop, the 65 Court Street HR Connect Service Center remains closed to walk-ins for the time being. THE NEW YORK CITY DEPARTMENT OF EDUCATION. Online Form. 1. Its programs and services, which benefit labor and Employee authorization: The employee must authorize this request, either by signing the form in Section 4, or by submitting it directly from his or her DOE email address. 2) Inquiries and questions can be emailed to healthbenefits@olr.nyc.gov. COBRA Form, ... NYC is a trademark and service mark of the City of New York. Form EB-1054, Health Benefits Report/Inquiry, must be filed by the responsibility center/school with the Medical, Leaves, and Benefits Office, 65 Court Street, Brooklyn, New York 11201. 125 does not apply to retirees. be contingent upon completion of a background investigation AND/OR a assessment! Enter your SS, EIS ID or employee ID Medical Spending Conversion Form Notice... Administers the State Labor Law and related laws, rules and regulations expand / close in! 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