Forms

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Don't forget to sign the forms!

Medical Claim form - Use this form if your medical provider does not participate with OneNet PPO (formerly Alliance PPO LLC). 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; and
the name of the patient.

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; and
the name of the patient.

If your medical or specialty 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 an 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.
Intent to Claim Tax Exemption (ITAX)	Married member adding stepchildren.
Letter of Support	This document is used in conjunction with the ITAX form.
Life Event form	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 form	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

*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.

Full-time Students

FORMS SCENARIO

Student Certificate Dependent children that are between the ages of 19 and 23 and are a full-time student may remain on your coverage provided proof of student status is received.

At the beginning of the month in which your child reaches age 19, you will be sent an Annual Request for Student Certification. You and your college student must read, sign and return the form to EWTF. Upon receipt of the form EWTF personnel will update your college student's coverage thru the date listed on the form. Dependent eligibility is contingent upon the member meeting the eligibility requirements of the Plan. This form can be faxed to EWTF. The fax number is (301) 731-1065.

Designating your Beneficiary

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

FORMS SCENARIO

Beneficiary form 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 enrollment 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 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

Enrollment form To update other insurance information for your spouse and/or dependent children

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.

FORMS	SCENARIO
Student Certificate	Dependent children that are between the ages of 19 and 23 and are a full-time student may remain on your coverage provided proof of student status is received.

FORMS	SCENARIO
Beneficiary form	Use this form to designate your beneficiary

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

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.