Retiree Health Services
Serving retirees of Local Funds
191 404 443 493 671A 1035
609 West Johnson Avenue
2nd floor
Cheshire, CT 06410
Hours
Monday - Friday
8:30 a.m. - 4:30 p.m.
Phone: 800-292-8340
Fax: 203-250-1232
Please watch your USPS mail for important plan information
Please return your 2024 Annual Information Request form
Please show your ID card to the health care provider
Your id starts with TSJ followed by 7 numbers.
Important information is located on back of card
Fill in forms to print and mail
The below forms are here for your convenience. Please contact Retiree Health services office first when submitting a claim or providing information.
Change of address
Designation of Beneficary
Annual Information Request
Plan SR Application
Benefit payment via Pension
Benefit Cancellation
Covid 19 over the counter test kit Reimbursement
Death Benefit Application
Authorization to release PHI
Directions to Health Services office
Summary Annual Report
Document & Information Check list
Complete Annual Information Request form
Address(you or your dependents) Birth ,Marriage,Death Certificate
Telephone Beneficiary designation
Family status (such as marriage) Divorce Decrees
Covered by other insurance Court Ordered Health Coverage
Claims payment may require:
How, When and Where an injury occurred
Information about other Insurance
Information about any action against Third Party
Reimbursement Agreement form
Claim filing limit is 2 years from date incurred
Request an appeal within 180 days from the claim denial