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Health Fund Forms

Personal Information Forms

  • Address Change Packet - (includes all 3 forms listed below)
    • Address Change Form - It is very important that the Administrative Office has the Participant's/Beneficiary's updated address for Plan correspondence. If the Participant/Beneficiary recently moved, please complete all necessary components of this Address Change Packet and return it to the Administrative Office.
    • Authorization to Release Information - Health Fund - Complete this form if you would like to authorize a person or entity to receive Health and Welfare information on your behalf.
    • Revocation-Restriction Form - Complete this form if you would like remove a person or entity that you have previously authorized to receive Protected Health Information (PHI).
    • Authorization to Release Information - Pension Plan - Complete this form if you would like to authorize a person or entity to receive Pension information on your behalf.
  • Dependent Enrollment Form - Use this form to add dependents to your insurance policy.
  • Dependent Dis-Enrollment Form - Use this form to notify the Fund office to terminate coverage for one or all of your dependents.
  • Legal Name Change Form - Use this form to notify the Fund office that you or your dependent(s) have recently had a legal name change. Also, use this form if you discover that your name or your dependents' name is spelled incorrectly.
  • Designation of Beneficiary for Life Insurance - Use this form to designate a beneficiary for life insurance.

Eligibility Forms:

  • COBRA Enrollment Packet - Use this packet to enroll in the COBRA Continuation Program if your Health Fund coverage has ended within the last 60-days.
  • Extended Coverage Election Form - Use this form to change your plan election when you first become covered under the Extended Coverage Program.

General Claims and Disability Forms:

Dental Claims:

IMPORTANT: Each packet is 40 to 80 pages in length. Please be sure you view the information before printing. Only the enrollment form (page 1) needs to be returned to the Fund Office.

Medical Claims:
  • Participant Submitted Claim Form - If you are filing your own claim, you must submit this form directly to your Local BlueCard/Anthem Blue Cross office accompanied by an itemized bill from the rendering providerIt is recommended that you retain copies of the claims you are submitting.
  • HCFA-1500 Form - This form should be used by providers submitting directly to the local Bluecard/Blue Cross office, accompanied by an itemized bill with the diagnoses and procedure codes. If this is a direct submission from a participant, refer to the "Participant Submitted Claim Form" in this section.
  • Medical Coordination of Benefits Form - 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.
  • Disability Application Packet - Complete this application to apply for a disability extension of coverage under the Fund.  Please note: a portion of this form must be completed by your attending physician.  Please be sure all sections of the application are complete and the form is signed before returning it to the Fund for processing.
  • Bluecard Worldwide International Claim Form - If you're filing a foreign claim you must submit this form directly to the address listed on the Bluecard Worldwide International Claim Form.
  • Provider - 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.
  • Accident Details - 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.
Prescription Claims
  • Express Scripts Mail Order Form - This form is used by the participant for mail order prescriptions. Please complete the form and attach scripts obtained from your doctor for all “maintenance drugs” you and/or your covered dependents use. The address to mail the completed form is noted on the bottom of the form.
  • Express Scripts Fax Form - This form is used by the prescribing physician for mail order prescriptions. Your doctor can fill out this form, attach a copy of your prescription and fax it to Express Scripts.
  • Health Allergy & Medication_Questionaire - This form is to help protect you against potentially harmful drug interactions and side effects. Express Scripts will alert your pharmacist about possible drug allergies and interactions that can be harmful.
  • Express Scripts Coordination of Benefits/Direct Claim Form - This form is needed to submit prescription drug claims under the Coordination of Benefits Rule.
  • 2015 Express Scripts Preferred Drug List - The list includes the most commonly prescribed drugs. It represents an abbreviated version of the drug list that is at the core of your prescription-drug benefit plan.
  • 2015 Express Scripts Preferred Drug List Exclusions - As of Jan. 1, 2015, the excluded medications shown on this list are not covered on the Express Scripts drug list. In most cases, if you fill a prescription for one of these drugs after Jan. 1, you will pay the full retail price.
Vision Claims
  • VSP Vision Benefits Information - This notice describes the PWGA’s new Vision Benefit administered and insured by VSP effective July 1, 2017. VSP is a nationwide network of eye care and eyewear providers. All eligible participants (excluding participants covered under the Low Option Plan) will automatically be enrolled in the new VSP vision program.
  • VSP Vision Claim Form/Non-Traditional Providers - This form is needed to submit Vision claims for services rendered by non-network VSP providers on or after 7/1/2017. Claims must be filed with VSP no later than 12-months after the date of service.
  • Davis Vision Claim Form/Non-Traditional Providers – This form is needed to submit Vision claims for services rendered by non-network Davis Vision Providers prior to 7/1/2017. Claims must be filed with Davis Vision no later than 12-months after the date of service.

Health Privacy Information:

  • HIPAA 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.

Official Plan Documents:

 

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