Forms

Complete & Print Forms – You can complete most of the forms listed below right on your computer before you print. Simply click on a field in the form and type in the appropriate information. Then print the completed form, sign and mail it to the Trust Office.


Claim Forms

General

  • Change of Address Form – Use this form to change your record of address. It is important to keep your address up to date with the Fund.
  • Designation of Beneficiary Form – Use this form to designate beneficiaries.
  • Express Scripts Mail Order Form – Use this form to order prescriptions by mail from Express Scripts.
  • Health Survey Form – This document must be submitted to the fund office to insure your spouse and/or children.
  • Newborn Registration Form – This form must be submitted to the Fund office to insure your newborn baby.  Subject to the Fund’s receipt of the baby’s birth certificate and Social Security Card, coverage will be effective as of the later of the baby’s date of birth or thirty (30) days prior to the date the Fund office is notified in writing of the baby’s birth.
  • Waiver of Benefits Form – Use this form to voluntarily waive  participation in the Fund for hospital, death, medical, dental, prescription, vision and any other Fund benefits.

HIPAA

  • Authorization to Release Information (Participant) – Use this form to authorize the I.B.E.W. Local 25 Health & Benefit Fund to use or disclose Protected Health Information to an individual concerning myself in connection with determination of eligibility for benefits, enrollment, treatment, payment of medical expenses and/or administration of the Fund.
  • Authorization to Release Information (Participant, Spouse, Dependents under 18) – Use this form to authorize the I.B.E.W. Local 25 Health & Benefit Fund to use or disclose Protected Health Information concerning participant, participant’s spouse and dependent children under the age of 18  in connection with determination of eligibility for benefits, enrollment, treatment, payment of medical expenses and/or administration of the Fund.
  • Authorization to Release Information (Dependents OVER 18) – Use this form to authorize the I.B.E.W. Local 25 Health & Benefit Fund to use or disclose Protected Health Information  in connection with determination of eligibility for benefits, enrollment, treatment, payment of medical expenses and/or administration of the Fund.

Time Loss Forms