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H & W Forms

Health & Welfare Forms

Note: Please make sure that you are eligible for Health and Welfare benefits before incurring any medical expenses or submitting claims to the Fund Office.

File Type Size Last Updated
Benefits at a Glance362 KBNov 15, 2022
Dental - Direct Reimbursement Form69 KBNov 15, 2022
Dependent Update Form282 KBNov 15, 2022
Disability Notice165 KBNov 15, 2022
Physician’s Medical Referral120 KBNov 15, 2022
Private Duty Nursing Form169 KBOct 15, 2019
Prescription Drug - Drug Claims Transmittal Form322 KBNov 15, 2022
Prescription Drug Maximum Purchase Exception130 KBNov 15, 2022
Prescription Drug - Special Authorization Request239 KBAug 11, 2021
NEW  Self-Pay Pre-Authorized Debit (PAD) Plan Agreement398 KBFeb 16, 2024
Self-Pay Bank Change Form58 KBNov 14, 2019
Self-Pay Cancellation Notice of Pre-Authorized Debit (PAD) Plan Agreement93 KBOct 15, 2019
Supplementary Health Expense Form165 KBNov 15, 2022
Supplementary Health Expense Form - Supplies141 KBNov 15, 2022
Supplementary Health Expense Form - Orthopedic Boots296 KBNov 15, 2022
Supplementary Health Expenses Form - Orthotic Inserts310 KBNov 15, 2022
Supplementary Health Expense Form - CPAP Machine and Supplies170 KBNov 15, 2022
Vision - Direct Reimbursement Form118 KBNov 15, 2022
Supplementary Health Expense - Private Duty Nursing196 KBNov 15, 2022