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| Due to date sensitivity of enrollment, you may request the following forms by contacting the Administrative office.- Cobra Election Form
- Delta Care (DMO) Enrollment Form
- Extended Coverage Election Form
- Open Access Enrollment Form
- Same Sex Domestic Partnership Information Packet
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General |
- Change of address form - Change of address form
- PacifiCare Behavioral Health Claim Form - use this form to submit a
claim to PacifiCare Behavioral Health
- Designation of Beneficiary for Life Insurance - Use this form to designate a beneficiary for life insurance.
- Dependent Enrollment form - Use this form to add dependents to your insurance policy.
- W-9 Form - This link provides the IRS form that must be completed by all new providers being added to the Fund's provider file. If claims have been denied for the W9 form, this form can be printed and given to your provider for submission to the Fund office. This form is required by the IRS before benefits can be released to a provider of service.
- Coordination of Benefits - This form is needed to update the Fund office with your Coordination of Benefits information. You should provide the Fund office with an updated form annually.
- Prescription Drug Reimbursement Form - This form is needed to submit claims for reimbursement for medication purchased.
- Coordination of Benefits/Direct Claim Form - This form is needed to submit prescription drug claims under the Coordination of Benefits Rule.
- Medco Mail Order Form - This form is used for the Mail Order Pharmacy Benefit. Please complete the form and attach scripts obtained from your doctor for all "maintenance drugs" you and/or your covered dependents use.
- Lien and Reimbursement Agreement - Have you been involved in an accident? Did you slip and fall while you were on someone else's property? Did someone else cause an injury to you? If so, this "Third Party Liability" coverage may be responsible for providing reimbursement for your medical care. The Fund office will deny all accident related charges until the form is completed, signed and returned.
- Disability Application - This is one of two forms needed to apply for a disability extension of coverage under the Fund. Please complete your portion of this form and return it to the Fund Office with a completed Attending Physicians Statement.
- Attending Physicians Statement - This form is one of two needed to apply for a disability extension of coverage under the Fund. Please have your doctor complete this form and return it to the Fund Office with a completed Disability Application.
- Dental Claim Form - Use this form to submit a claim to Delta Dental.
- Student Certification - In order to extended coverage for your dependent child(ren) who are full time students and are between the ages of 19 and 23. Please complete and sign your portion, have the school Registrars' Office complete and sign their portion and return it to the Fund Office for processing.
Health Information Privacy |
- Privacy Notice - In compliance with the HIPAA regulation, the Fund office has developed a Privacy Notice advising our Participants of their rights under this regulation.
- Authorization for release of health information form - In compliance with HIPAA regulations, this form provides authorization for the identified person to receive Protected Health Information (PHI) on a particular persons medical care or payment of health insurance benefits. The form must be precise in the information and time period this information is permitted to be disclosed.
Official Plan Documents |
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These printable forms are in PDF (Portable Document) format.
To read and print them, you need the free Adobe Acrobat Reader (which is probably already installed in your system). If you do need to install it, click the "Get Acrobat Reader" logo.
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