NYCEDWF Forms ─ Stay Tuned for More Updates

NYCEDWF Prescription Form

1Status & Contact

Patient's Email Address

Membership Status

Active Member

2Patient Information

Last Name

First Name

Middle Initial

Gender

Male Female

Date of Birth

Member's Local 3 Card #

3Member Information

Last Name

First Name

Middle Initial

Member's Social Security #

Prescription(s) for: (use one form per patient)

Member Spouse Covered Child

4Home Address

Home Address

Apartment #

City

State

Zip Code

Home Telephone Number

5Employment

NYC Agency for Which Member Works or Worked

Member's Job Title

Work Location and Address

Work Telephone Number

Member's Branch of Electrical Division

If "Other," please specify

6Other Insurance Coverage

Is the patient named above covered by any other welfare fund or group health insurance provider?

Yes No

If "Yes," please supply the following information concerning the aforementioned plan(s):

Relationship of Patient to Member

Plan Provider

Plan Name

Membership #

Other Pertinent Information

7Prescription Information

Submit actual bills or receipts for purchases made within the past 120 days only. Use only one form per patient.

	Purchase Date	Prescription #	Name of Medication	Classification	Quantity	Doses/Day	Pharmacy Name & Location	Price
1				Name Brand Generic
2				Name Brand Generic
3				Name Brand Generic
4				Name Brand Generic
5				Name Brand Generic
6				Name Brand Generic
7				Name Brand Generic
8				Name Brand Generic
9				Name Brand Generic

8Certification & Authorization

By typing your name below, you certify that the medications listed were prescribed for the patient named above, and you authorize release of related claim information as described on the official form.

Signature of Member (Certification of Claim)

Date

Signature of Member (Authorization to Release Info)

Date

Your information is processed entirely in your browser to build the PDF — nothing is uploaded to a server. Return the completed, signed form to: NYC Electrical Division Health & Welfare Fund, P.O. Box 479, Fresh Meadows, NY 11365-0479.

NYCEDWF Forms ─ Stay Tuned for More Updates

Optical Claim Form

1Member Type

2Patient & Insured Information

3Authorization & Signatures

Prescription Form