Forms and information
Forms
Call us at 855-405-3863 if you need help with these forms.
Appeal filing form
Application to convert group life insurance
Authorization for release of protected health information
Continuity of care request form
Late self-payment request/appeal form
Life insurance beneficiary form
Pharmacy mail order form
Pharmacy prior authorization initiation form
PHI restriction request form
Prescription reimbursement claim form
Request to inspect or receive a copy of protected health information
Short-term disability form
1095-B tax form
Information
Get to know your benefits. It will help you know what is available to you. To find out about your benefits, call us at 855-405-3863, or download a copy of your Participant Guide.
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Benefits at a glance
View your Benefits at a Glance:
- 2023
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Summary Annual Report
Download a copy of your Summary Annual Report (SAR).
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Summary of Benefits and Coverage
Download a copy of your Summary of Benefits and Coverage (SBC). It gives you a quick outline of some of your benefits and costs.
Hospitality Plan
- Effective January 1, 2024
Cache Creek
- Effective January 1, 2024
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Summary Plan Description
View your Summary Plan Description (SPD). It explains all of your benefits.
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Summary of Material Modifications
After each SPD is published, certain changes may have been made to your benefits. These changes are reflected in a Summary of Material Modifications (SMM).
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Evidence of coverage
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Delta Dental
- Online
- Call: 800-422-4234
Disregard the Eligibility and Termination sections in the EoC. The Fund determines who is eligible.
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Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory (outpatient) surgical center, you are protected from “surprise billing” or “balance billing.” More information
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Healthcare Reimbursement Account (HRA)