Forms

 

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The medical and dental claim forms that can be downloaded here still have the old office address listed.  These forms will not be updated until we have used the existing supply in the office. 

Don't forget to sign the forms!

Medical Claim form - Use this form if your medical provider does not participate with UnitedHealthcare Choice Plus Network or if Medicare is your primary coverage. Complete forms for each patient's medical provider and sign where indicated. Attach an itemized bill that includes: 

  • the name of the medical provider
  • the address and telephone number of the medical provider
  • the date of service(s)
  • the Current Procedure Terminology (CPT) code(s)
  • the billed amount for each service
  • the name of the patient
  • attach the Medicare Explanation of Benefits

Submit your medical claims to:

Electrical Welfare Trust Fund
10003 Derekwood Lane, Ste 130
Lanham, MD 20706-4811

Dental Claim form - download this form and give to your dentist to complete or attach an itemized bill that includes: 

  • the name of the dental provider
  • the address and telephone number of the dental provider
  • the date of service(s)
  • the American Dentistry Association (ADA) code(s)
  • the billed amount for each service
  • the name of the patient

If your dental provider participates with OneNet PPO the staff of the provider's office will submit a claim on your behalf to OneNet for pricing. OneNet forwards the claims to EWTF for consideration.  It is important that you present your EWTF ID card which is also your Caremark prescription card to all OneNet providers. By showing the card each time you visit a OneNet provider you can be assured that your claim is priced according to the agreement and that your claim is routed to EWTF for consideration.  The EWTF group number is AM0011.

Adding a Spouse or Dependent Children

Below are some of the forms required to add a spouse or dependent. If more information is needed you will be contacted. Please read the scenarios next to the forms so that you are using the correct form to add your dependents including your spouse.

FORMS  SCENARIO
Enrollment Form Complete this form for any situation other than adding a spouse for a first marriage* or a married member adding a newborn child+. For these two scenarios use a Life Event form.
Life Event Use this form if you are newly married* with no previous spouses on file and wish to add your spouse; if you are married and your spouse is already listed as a dependent and you are adding a newborn+.
Dependent Verification Single member adding a child; participant working under Local 26 jurisdiction begins living separate and apart, is legally separated or divorced and pays support for natural children.
Enrollment Form for Adult Dependent Coverage Complete this form if you wish to add or reinstate an adult dependent (between the ages of 19 and 26) to your EWTF coverage.

*Submit a copy of your marriage license or certificate with the completed form.
+Submit a copy of your child's birth certificate or a verification of birth from the medical records department at the hospital where your child was born.

Designating your Beneficiary

If you would like to designate a beneficiary for the EWTF death benefits, please download this form:

 

FORMS  SCENARIO
Beneficiary Use this form to designate your beneficiary

Remember to keep your beneficiary information up-to-date and current.

Updating your Other Insurance Information

If your spouse or dependent children's health insurance status should change, please submit an Other Insurance Update form.  If they are obtaining coverage for the first time or are changing insurance carriers, submit a copy of the front and back of the insurance card as well.  If their coverage is ending and they are not going to have any other insurance besides the EWTF coverage, submit a copy of the Letter of Termination.

The Fund office will request an update of other insurance information at least every two years. 

 

FORMS  SCENARIO
Insurance Update

EWTF requires this information if there are any changes as shown below:

  • you or covered family members obtaining any other health coverage 
  • adding a dependent to the other coverage
  • adding or removing a type of coverage (adding dental coverage)
  • the name of the company providing the health coverage (for example, from BC/BS to ULLICO)
  • the other coverage is terminated

Claims

Statement of Injury forms are often requested from EWTF participants.  When you complete this form, be sure to complete all of the information.

 

FORMS  SCENARIO
Statement of Injury This form is mailed to participants when information has been received that indicates a possible accident or injury.

Privacy

 

FORMS  SCENARIO
Appointment of Personal Representative This form authorizes EWTF to give protected health information to the named individual.
Privacy Notice This document was mailed to all eligible participants in April 2003 and to all newly eligible and reinstating participants since then.


 

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