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.
- Decline Retiree Coverage (Opt Out) Election Form – Complete this form to decline coverage under the retiree benefit.
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)
- HRA Claim Form – Use this form to request reimbursement from your HRA
- Annual Notice: Right to Opt-Out of HRA – Use this form to opt-out of the HRA.
Prescription Drug
- SavRx Mail Order Prescription Form – Use this form to order prescriptions through the SavRx Mail Order Program.
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
- Weekly Disability Benefits Claim Form – Complete this form when applying for Weekly Disability benefits.
Life and Accidental Death and Dismemberment (AD&D)
- Life and AD&D Insurance Claim Form – Complete this form when applying for Life or AD&D insurance benefits
- Beneficiary Designation Form – Use this form to designate or update your beneficiary information.
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Documents
Summary Plan Descriptions Summary Plan Descriptions (SPDs) describe your 4th District IBEW Health Fund benefits, including what’s covered, what’s not […]