Form Hr Ben 066 PDF Details

Understanding the HR-BEN-066 form is crucial for employees who find themselves in need of short-term disability benefits, highlighting the importance of this document in providing financial support during times of illness or injury. When an employee faces a medical condition that temporarily hinders their ability to work, navigating through the process of claiming short-term disability benefits becomes essential. The HR-BEN-066 form serves as a bridge between the affected employee and the necessary financial assistance, requiring detailed information including the employee's personal data, specifics about the illness or injury, and the treatment received. It mandates that both the treating hospital or physician complete certain sections and that the employee provides information on other benefits they might be receiving, ensuring a comprehensive understanding of the employee's situation. Essential details such as the name and contact information of the employee's supervisor, the nature of the illness or injury, and the employee's eligibility for other benefits like Worker’s Compensation or Federal SSA Disability Benefits must be accurately reported. With the requirement for the form to be either faxed or emailed to specified contacts, it underscores the procedural aspect of initiating a claim. Offering a beacon of hope, the form also outlines a path for recovery and eventual return to work, addressing the employee's capacity for work upon recovery, whether it's on a full-time, part-time, or light duty basis. Understanding the intricacies of this form can indeed make a significant difference for employees navigating through challenging times of illness or injury.

QuestionAnswer
Form NameForm Hr Ben 066
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesSSN, MTA, Suffix, BSC

Form Preview Example

Short Term Disability Form

HR-BEN-066

Section 1 - Information and Instructions

The purpose of this form is to apply for short term disability benefits. The hospital and/or Physician responsible for treating the patient must complete the reverse side of this form.

Please fax a signed copy of the form to 212-852-8700 or e-mail a signed copy of the form to bscservice@mtabsc.org.

If you have any questions, please contact MTA Business Service Center (BSC) at 646-376-0123 or bscservice@mtabsc.org.

Section 2 - Employee Information

Print Name

 

 

 

 

 

 

BSC ID

 

Last

 

First

 

M.I.

Suffix

 

 

 

 

 

 

 

 

Agency

BSC

B&T

CC

HQ Civilian

HQ Police

 

 

 

 

 

 

 

Department

(check one)

LI Bus

LIRR

MNR

MTA Bus

NYCT

 

 

 

 

 

 

 

 

 

 

 

Street Address

City

State

Zip Code

Phone (H)

Phone (W)

E-mail

Employee’s Supervisor / Dept. Head

Supervisor’s Phone

Section 3 - Illness / Injury Information

Illness / Injury Date

Occupation-Based Illness / Injury

Yes

No

Report Type Initial

Follow-up/Interim

Other (Explain)

Location Where Injury Occurred

Section 4 - Other Benefits Employee is Receiving

Check all that apply.

 

 

 

None

 

Worker’s Compensation

Dates (from/to)

Personal Injury Damages

Dates (from/to)

Federal SSA Disability Benefits

Dates (from/to)

Railroad Retirement

Dates (from/to)

 

 

Other (Provide Dates)

Dates (from/to)

 

 

Indicate any Short-Term Disability benefits

 

previously received from other MTA Agencies

 

 

 

 

 

Section 5 - Authorization

 

 

 

 

 

 

 

 

 

Employee Signature

 

Date

SSN Last 4 Digits

 

 

 

 

 

Signature of Person Other Than Employee

 

Date

 

 

 

 

 

 

Print Name and Relationship

 

 

 

 

 

Physician must complete this section

 

 

 

 

 

Business Service Center HR-BEN-066

 

 

 

Page 1 of 2

 

 

 

Short Term Disability Form

HR-BEN-066

Section 6 - Hospital Certification (if applicable)

Hospital Name

 

 

 

Main Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

Hospital Address

 

 

 

 

 

 

 

 

Street

 

City

 

State

Zip

 

 

 

 

 

 

 

 

 

 

 

Description of Treatment / Surgical Procedure

 

 

 

 

 

 

 

Additional Information Attached

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hospital Stay

 

 

 

 

 

 

 

 

Admittance Date

 

Discharge Date

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Hospital Official

 

 

Title of Hospital Official

 

 

 

 

 

 

 

 

 

 

 

Signature of Hospital Official

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 7 - Physician’s Certification

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician’s Name

 

 

 

Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician’s Address

 

 

 

 

 

 

 

 

Street:

 

 

City:

State:

Zip:

 

 

 

 

 

 

 

 

 

Period of Treatment

From date(s)

To date(s)

 

 

 

 

 

 

 

 

 

First date unable to work

Date suitable to return to work

Work-related condition?

Yes

No

 

 

 

 

 

 

 

 

Employee may return to work as follows

 

 

 

 

 

 

 

(Check all that apply)

Full-time

Part-time

Temporarily (provide details)

Full duty

Light duty

 

 

 

 

 

 

 

 

 

 

Description of condition, diagnosis or treatment

 

 

 

Physician’s tax I.D. number

 

 

 

 

 

 

 

 

 

Additional Information Attached

 

 

Date(s) of future treatment(s)

 

 

Physician’s Signature

Date

Physician’s Seal must be placed here.

Business Service Center HR-BEN-066

Page 2 of 2

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1. To start off, when filling in the applicable, start out with the part with the following fields:

Completing section 1 of SSA

2. The next part would be to submit all of the following fields: Check all that apply, None, Workers Compensation, Personal Injury Damages, Dates fromto, Dates fromto, Federal SSA Disability Benefits, Dates fromto, Dates fromto, Dates fromto, Railroad Retirement, Other Provide Dates, Indicate any ShortTerm Disability, Section Authorization, and Employee Signature.

SSA writing process described (stage 2)

People generally get some points wrong while completing None in this section. Make sure you read again whatever you enter right here.

3. This next stage is straightforward - fill in all of the blanks in Section Hospital Certification, Hospital Name, Hospital Address, Main Phone Number, Street City State Zip, Description of Treatment Surgical, Additional Information Attached, Hospital Stay, Admittance Date Discharge Date, Name of Hospital Official Title of, Signature of Hospital Official Date, Section Physicians Certification, Physicians Name, Physicians Address, and Phone Number in order to complete the current step.

The right way to fill out SSA step 3

4. All set to complete this fourth portion! Here you have these Physicians Address, Street City State Zip, Period of Treatment From dates To, First date unable to work Date, Yes, Employee may return to work as, Check all that apply, Fulltime, Parttime, Temporarily provide details, Full duty, Light duty, Description of condition diagnosis, Physicians tax ID number, and Additional Information Attached blanks to complete.

The best way to prepare SSA portion 4

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