Welfare Forms

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Enrollment Form with Required Documents List

  • Every eligible member must complete an Enrollment Form in order to activate their eligiblity for benefits. A new form must be completed to add dependents to a plan.

Adult Child Form

  • Each adult child must complete this form upon attaining age 19 or when first enrolled in the plan and each calendar year thereafter.

Member Update Form

  • Every eligible member must complete this form each calendar year. Charges cannot be processed until this fully completed form is received.

Disability Claim Form

  • Members can use this form to file for weekly income benefits if you become disabled.

Prescription Drug Claim Form

  • Use this form to seek reimbursement on prescription drugs that you have paid out of pocket.

LDI Mail Order Drug Form

  • After you have filled two consecutive 30-day fills of a prescription at a retail pharmacy you may take advantage of the mail order program on your long-term maintenance drugs.

Notice of Privacy Practices

  • In compliance with HIPAA, this Notice describes your rights concerneing your health information and describes our practices related to your health information. Please take the time to review this Notice carefully.

Authorization to Release Health Information

  • One of the most significant effects of the privacy laws is that the Welfare Fund may no longer discuss your health information (including eligibility information) with your family members without your specific written authorization. Please have each family member that is 18 years old and over complete an authorization.

Revocation of Authorization to Release Health Information

  • Use this form to deny any previously authorized representative access to your information.

Change of Address

  • Use this to notify the Fund’s of your new address.

Incapacitated Child Form

  • Required documentation to determine if eligible for continued coverage beyond the limiting age.

Appeal Request Form

  • Use this form to appeal a claim that has been wholly or partially denied.