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Health Forms

2018 Coordination of Spouse Employer Cover Letter - Cover Letter for Coordination of Spouse Benefit Form.

2018 Coordination of Spouse Employer Form - Form to be submitted for verification of spouse's benefits.

2018 Dependent Age 19 - 26 Cover Letter - Cover Letter for Dependent to Age 26 Enrollment Form.

2018 Dependent Age 19 - 26 Form - Form to be submitted for verification of dependent enrollment.

Change of Address- Form to notify the Fund office if you change your mailing address.

Enrollment Form - Form for enrolling for benefits.

Enrollment Form for Municipalities - Form for enrolling for benefits. This is for Municipal Employees Only.

Enrollment Form Instructions - Form for enrolling for benefits. This is for Municipal Employees Only.

HIPAA Privacy Notice - Notice regarding the Health Insurance Portability and Accountability Act 0f 1996.

HIPAA Authorization Form - Form to release personal information to a third party.

Rx Reimbursement - COB Claim Form - Form for Prescription COB Claim Reimbursement.

Mail Order Rx Fax Back Form from Provider - Form for Prescription Fax Back from Provider.

Home Delivery Rx Order Form - Form for Mail Order Home Delivery Prescriptions.

 



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