Member Services Problems Log: Health/Dental

Please use this form to log member problems

Member first name: *

Member last name: *

Member pass #: *

Member's department:

Member's phone (home or cell):

Member's email:

Member's status:

Caller's relation to member:

Member

Child

Spouse

Issue regards:

Member

Child(ren)

Spouse

Domestic Partner

Carrier:

United Healthcare

Empire BC/BS

Empire BC/BS Hi Opt

AETNA

Dental Plan A

Dental Plan B

Dental Hi Opt

Prescription

Vision

Outcome:

Referred to BSC

Sent Form(s)

Sent Form

Gave Information

Other

Comments:

Was a Member Services case file opened that needs follow-up?: *

BSC ticket number, if one has been assigned:

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New York's Public Transit Union • Transport Workers Union Local 100 • 195 Montague St 3rd floor, Brooklyn, NY 11201