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 Funds Office.
Claim Forms
- Davis Vision form – Complete and return this form to request reimbursement for services received from providers who do not participate in the Davis Vision network.
- DDS Dental Claim Form – This form is used to submit dental claims.
- Express Scripts Reimbursement Form – Complete and return this form when you have purchased a covered prescribed prescription drug at retail cost and are seeking reimbursement.
- MagnaCare Claim Form – Complete and return this form to MagnaCare. Your physician may need to fill out a portion of this form.
- Supplemental Unemployment Benefit Claim Form – Use this form to submit a claim for supplemental unemployment benefits.
General
- No Surprises Act Notice – When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing. Learn about your rights and protections against Surprise Medical Bills.
- 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.