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Active

Forms for the Active, COBRA and Low Cost Medical Plan of Benefits - Return completed forms to the Participant Services Dept. at the Fund Office.

Please click on title of form to download and print.

Aetna Life Insurance Continuation Form- Participant’s Statement

This is one of two forms required to be completed to apply for the continuation of the participant’s Welfare Fund life insurance benefit when a participant has become totally and permanently disabled prior to reaching 60 years of age.

Aetna Life Insurance Continuation Form- Physician’s Statement

This is one of two forms required to be completed to apply for the continuation of the participant’s Welfare Fund life insurance benefit when a participant has become totally and permanently disabled prior to reaching 60 years of age.

Appeal Form (Welfare Claims)

A Participant, patient or Authorized Personal Representative generally has the right to appeal denial of enrollment, eligibility for benefits or a claim for benefits that was denied in whole or in part.

Authorization to Release Medical Information Form

A covered individual may designate a person/organization to provide or receive protected health information by completing an Authorization to Release Medical Information Form.
 

Authorized Personal Representative Designation Form

A covered individual may designate an Authorized Personal Representative to act on his behalf when appealing denial of enrollment, eligibility for benefits or a claim for benefits that was denied, in whole or in part, by completing an Authorized Personal Representative Designation Form and submitting it with the Appeal Form.

COBRA - Notice of Continuation Procedures (Active Plan)

This document explains who qualifies for COBRA, the types of qualifying events, the maximum period of coverage, payment deadlines, the Low Cost Medical Plan, adding a dependent while on COBRA or Low Cost, reasons for termination of coverage and converting to an individual policy after you exhaust the maximum period of coverage under COBRA or the Low Cost Medical Plan.

Dependent Add Form

You may use this form to add a new dependent based on an event where there are newly-eligible dependents to add to the plan (for example, you marry and want to add your step-children to the plan,  you have a new baby or you adopt a child).  Documentation requirements apply.  The Participant Information Form may also be used for this purpose, but remember to include all of your covered dependents when using that form, not just the ones you are adding.

Dependent Drop Form

You may use this form to drop a dependent based on an event where dependents are no longer eligible for the plan.  For example, you divorce your spouse and his/her children (the Carpenter’s stepchildren) need to come off the Plan, or if a dependent child gains coverage elsewhere and no longer needs this Plan (has coverage through their employer/job).  The Participant Information Form may also be used to drop dependents, but remember to include all of the dependents you want to remain covered when using that form.

Disabled Adult Children - Attending Physician's Statement

This is one of two forms required to be completed to apply for continuation of insurance for an overage child that is permanently physically or mentally disabled.

Disabled Adult Children - Participant's Statement Form

This is one of two forms required to be completed to apply for continuation of insurance for an overage child that is permanently physically or mentally disabled.

Enrollment and Life Insurance Beneficiary Designation Form

Completion of this form is mandatory for enrollment to the Plan and required in order to add or remove your eligible dependents. This form is also used to designate the beneficiary for the life insurance benefit if applicable.

Enrollment and Life Insurance Beneficiary Designation Form (Spanish Version)

(Forma de Inscripcion y Designacion de Beneficiario para Seguro De Vida)
Llenar y completar esta forma de inscripción y designación es mandatorio para inscribirse al Plan y requerido para agregar o remover sus dependientes elegibles.  Esta forma también se utiliza para designar su beneficiario en caso de fallecimiento.

ESI Prescription Drug Reimbursement Form

This form should be used to request a reimbursement from Express Scripts for prescriptions paid out of pocket.

Expedited Review Form

A Participant, patient or Authorized Personal Representative generally has the right request an expedited review if the adverse benefit determination involves a medical condition of the claimant for which the timeframe for the completion of a standard appeal would seriously jeopardize the life or health of the claimant or would jeopardize the claimant’s ability to regain maximum function or, if in the opinion of your physician, the patient would experience pain that cannot be adequately controlled.  If the above criteria is not met, the request for an Expedited Review will be denied.

External Review Form

If the Appeals Committee of the Board of Trustees has maintained denial of a claim, in whole or in or part, the Participant, Patient or Authorized Personal Representative generally has the right to request an external review.

Low-Cost Medical Plan

A brochure that describes the benefits available under the Low Cost Medical Plan, an alternative to COBRA.

Medicare Coverage; Mandatory Notification for Parts A & B

Please complete in order to comply with Medicare's mandatory reporting of Health Insurance Claim Numbers ("HICN") or Social Security Numbers ("SSN").

Natural Parent’s Affidavit of Dependency Form

To be completed and notarized when a natural parent does not have insurance for their child.

Notice of Need for COBRA to Administrator & Instruction Sheet

Notice to Administrator of a Qualifying Event in order to possibly extend COBRA coverage.

Participant Information Form - English Version

To be completed by new participants as well as on an annual basis for active participants covered by the Plan.

Participant Information Form - Polish Version

To be completed by new participants as well as on an annual basis for active participants covered by the Plan.

Participant Information Form - Spanish Version

To be completed by new participants as well as on an annual basis for active participants covered by the Plan.

Privacy Notice - HIPAA-HITECH - July 2016 (Active Plan)

Explanation of the privacy notice including a form to restrict access to your protected health information (PHI).

Qualified Medical Child Support Order(QMCSO) and National Medical Support Notice (NMSN) Procedures

This document outlines the Plan’s procedures for handling Qualified Medical Child Support Orders and National Medical Support Notices.

Short Term Disability Claim Form

To be completed by the participant and his attending physician to apply for the Weekly Benefit for Illness or Injury.
IRS Form W-4S,  Request for federal income tax withholding from sick pay. This form must be completed should you elect to have taxes deducted from your weekly disability benefit.

Short Term Disability Claim – Recertification Form

Physician certification of continuing disability.

Single Parent Dependent Affidavit

To be completed by the natural parent and notarized to determine whether a child born out of wedlock qualifies as a covered dependent under the Plan.

Stepchild Dependent Affidavit

To be completed to determine whether a stepchild qualifies as a covered dependent under the Plan.

Subrogation Agreement

To be completed when expenses for an illness or accident may be compensable by an action against a third party.

Summary Plan Description for the Active Plan of Benefits (English Version)

Describes the benefits under the Active Plan of Benefits.


Retiree

Forms for the Retiree Plan of Benefits - Return completed forms to the Pension Dept. at the Fund Office.

Please click on title of form to download and print. 

Appeal Form (Welfare Claims)

A Participant, patient or Authorized Personal Representative generally has the right to appeal denial of enrollment, eligibility for benefits or a claim for benefits that was denied in whole or in part.

Authorization to Release Medical Information Form

A covered individual may designate a person/organization to provide or receive protected health information by completing an Authorization to Release Medical Information Form.
 

Authorized Personal Representative Designation Form

A covered individual may designate an Authorized Personal Representative to act on his behalf when appealing denial of enrollment, eligibility for benefits or a claim for benefits that was denied, in whole or in part, by completing an Authorized Personal Representative Designation Form and submitting it with the Appeal Form.

Cancellation Form for Dependent Child (Retiree Benefits)

Use this form to cancel the Retiree Healthcare Benefits for your dependent child.

Cancellation Form for Participant and or Spouse (Retiree Benefits)

Use this form to cancel the Retiree Healthcare Benefits for either yourself or your spouse.

COBRA - Notice of Continuation Procedures (Retiree Plan)

This document explains who qualifies for COBRA, the types of qualifying events, the maximum period of coverage, payment deadlines, the Low Cost Medical Plan, adding a dependent while on COBRA or Low Cost, reasons for termination of coverage and converting to an individual policy after you exhaust the maximum period of coverage under COBRA or the Low Cost Medical Plan.

Enrollment for Dependent Children (Retiree Benefits)

If you, the retired carpenter, are already covered by the Retiree Healthcare Plan of Benefits, this is the information and the form that you need to add your dependent child to the plan.

Enrollment for Participants (Retiree Benefits)

If you, the retired carpenter, previously postponed or cancelled coverage by the Retiree Healthcare Plan of Benefits, this is the information and the forms that you need to enroll in the Plan.

Enrollment for Spouse (Retiree Benefits)

If you, the retired carpenter, are already covered by the Retiree Healthcare Plan of Benefits, this is the information and the form that you need to add your spouse to the plan.

Expedited Review Form

A Participant, patient or Authorized Personal Representative generally has the right request an expedited review if the adverse benefit determination involves a medical condition of the claimant for which the timeframe for the completion of a standard appeal would seriously jeopardize the life or health of the claimant or would jeopardize the claimant’s ability to regain maximum function or, if in the opinion of your physician, the patient would experience pain that cannot be adequately controlled.  If the above criteria is not met, the request for an Expedited Review will be denied.

External Review Form

If the Appeals Committee of the Board of Trustees has maintained denial of a claim, in whole or in or part, the Participant, Patient or Authorized Personal Representative generally has the right to request an external review.

Medicare D Creditable Coverage Notice

A notice describing the Plan’s prescription drug coverage and advising participant’s that the Plan’s prescription coverage is better than Medicare Part D coverage. It is important that Medicare eligible participants do not enroll in Medicare’s Part D prescription coverage.

Privacy Notice - HIPAA-HITECH - July 2016 (Retiree Benefits)

Explanation of the privacy notice including a form to restrict access to your protected health information (PHI).

Qualified Medical Child Support Order(QMCSO) and National Medical Support Notice (NMSN) Procedures

This document outlines the Plan’s procedures for handling Qualified Medical Child Support Orders and National Medical Support Notices.

Summary Plan Description for the Retiree Plan of Benefits

Describes the benefits under the Retiree Plan of Benefits.

 
 

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