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Forms

General

  • Fund’s Enrollment Form – Complete this form if you are newly eligible or experience a change in family status (e.g., marriage or birth of a child).
  • Proof of Other Insurance – Complete this form if you or a dependent has insurance coverage through another plan (e.g., your spouse’s employer).
  • Subrogation Agreement – The Fund has the right to recover payments it makes on your behalf for an illness or injury should you receive money as a recovery from another party for the same illness/injury.

Medical

  • Medical Plan Claim Form – Complete this form when submitting a medical claim for services rendered by a provider who does not belong to the Blue Cross Blue Shield network. (Blue Cross Blue Shield network providers will submit your claim on your behalf.)
  • Appointment of Authorized Representative Form – Use this form to authorize another person to act on your behalf in matters related to filing/appealing claims or privacy of protected health information.
  • HIPAA Authorization Form – Use this form to authorize other person(s) and/or organization(s)  to use and/or disclose your health information
  • SavRx Mail Order Prescription Form – Use this form to order prescriptions through the SavRx Mail Order Program.
  • HEALTHY LIFE Reference Card – Bring this reference card to your HEALTHY LIFE doctor’s appointment to make sure your exam covers the require

Health Reimbursement Arrangement (HRA)

Prescription Drug

Dental

  • Dental Claim Form – Complete this form when submitting a dental claim for services rendered by a dentist who does not belong to the Delta Dental network. (Delta Dental network providers will submit your claim on your behalf.)

Weekly Disability

Life and Accidental Death and Dismemberment (AD&D)