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 Glance | | 362 KB | Nov 15, 2022 |
| Dental - Direct Reimbursement Form | | 69 KB | Nov 15, 2022 |
| Dependent Update Form | | 282 KB | Nov 15, 2022 |
| Disability Notice | | 165 KB | Nov 15, 2022 |
| Physician’s Medical Referral | | 120 KB | Nov 15, 2022 |
| Private Duty Nursing Form | | 169 KB | Oct 15, 2019 |
| Prescription Drug - Drug Claims Transmittal Form | | 322 KB | Nov 15, 2022 |
| Prescription Drug Maximum Purchase Exception | | 130 KB | Nov 15, 2022 |
| Prescription Drug - Special Authorization Request | | 239 KB | Aug 11, 2021 |
| Self-Pay Pre-Authorized Debit (PAD) Plan Agreement | | 398 KB | Feb 16, 2024 |
| Self-Pay Bank Change Form | | 58 KB | Nov 14, 2019 |
| Self-Pay Cancellation Notice of Pre-Authorized Debit (PAD) Plan Agreement | | 93 KB | Oct 15, 2019 |
| Supplementary Health Expense Form | | 165 KB | Nov 15, 2022 |
| Supplementary Health Expense Form - Supplies | | 141 KB | Nov 15, 2022 |
| Supplementary Health Expense Form - Orthopedic Boots | | 296 KB | Nov 15, 2022 |
| Supplementary Health Expenses Form - Orthotic Inserts | | 310 KB | Nov 15, 2022 |
| Supplementary Health Expense Form - CPAP Machine and Supplies | | 170 KB | Nov 15, 2022 |
| Vision - Direct Reimbursement Form | | 118 KB | Nov 15, 2022 |
| Supplementary Health Expense - Private Duty Nursing | | 196 KB | Nov 15, 2022 |
