FORMS

AUTHORIZATION FOR RELEASE OF PHI FORM:

If you want the Plan to disclose your protected health information to another individual, persons, class of persons, or organization of your choice (e.g. your spouse), you must fill out this form and return it to the Fund office, Wilson-McShane Corporation. If your spouse and/or Dependent children over the age of 17 want the Plan to disclose their protected health information to you, they also must fill out this form and return it to the Fund office.

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CHANGE OF ADDRESS FORM:

Complete this form to change or correct your mailing address.

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CHANGE OF NAME FORM:

Complete this form to change or correct your name.

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FAMILY UPDATE FORM:

If you have a life event and need to update coverage for dependents, this form must be completed and sent to the Fund office, Wilson-McShane Corporation, with the appropriate documentation (e.g. birth certificate, marriage certificate, divorce decree, etc.). This form is also used to add coverage for dependents when you first become eligible.

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COMMON LAW MARRIAGE AFFIDAVIT:

If your marriage is a common-law marriage, you must complete this form, in addition to the Family Update Form, to add coverage for your spouse.

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INITIAL REPORT OF CLAIMS FORM:

If your provider does not automatically submit your bill to the Fund office, Wilson-McShane Corporation, please complete this form and return it to the Fund office with the itemized bills from your provider.

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HRA CLAIM FORM:

Complete this form to receive reimbursement from your Health Reimbursement Arrangement (HRA) balance (Iowa participants only).

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SUBROGATION & REIMBURSEMENT AGREEMENT:

Complete this form to acknowledge the Fund's subrogation and reimbursement interests. For more information regarding subrogation and reimbursement, please contact the Fund office, Wilson-McShane Corporation.

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INITIAL DISABILITY FORM:

If you become totally disabled and are unable to work, you and your physician must complete this form and submit it to the Fund office, Wilson-McShane Corporation, in order to receive Hour Bank Extension and Weekly Income Benefits.

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SUPPLEMENTARY DISABILITY FORM:

If your total disability period extends over multiple months, you and your physician must periodically complete this form and submit it to the Fund office, Wilson-McShane Corporation, in order to continue receiving Hour Bank Extension and Weekly Income Benefits.

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FORMS

AUTHORIZATION FOR RELEASE OF PHI FORM:

CHANGE OF ADDRESS FORM:

CHANGE OF NAME FORM:

FAMILY UPDATE FORM:

COMMON LAW MARRIAGE AFFIDAVIT:

INITIAL REPORT OF CLAIMS FORM:

HRA CLAIM FORM:

SUBROGATION & REIMBURSEMENT AGREEMENT:

INITIAL DISABILITY FORM:

SUPPLEMENTARY DISABILITY FORM:

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