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Family Update Form

If you have a life-changing event and need to update dependent information, this form must be completed and sent to the Fund Office, with appropriate documentation (birth certificate, marriage certificate, divorce decree, etc.).

HRA Election Change Form (Off)

The Fund will automatically reimburse you for deductible and coinsurance amounts from your HRA balance. If you do not want to receive automatic reimbursement, you should complete this form and submit it to the Fund Office.

HRA Claim Form

Complete this form and submit it to the Fund Office with appropriate documentation to receive reimbursement for Qualified Medical Care Expenses.

HRA Election Change Form (On)

If you previously notified the Fund Office that you did not want to receive automatic reimbursement of deductible and coinsurance amounts from your HRA balance, but wish to restore this automatic feature, you should complete this form and submit it to the Fund Office.

Change of Personal Information Form

Complete this form to change or correct your mailing address and/or name, and return it to the Fund Office.

Authorization for Release of PHI Form

If you want the Plan to disclose your protected health information to another person or organization (for example, your spouse), you must fill out this form and return it to the Fund Office. If your spouse or dependent child over the age of 17 wants the Plan to disclose their protected health information to you, they also must fill out this form and return it to the Fund Office.

Beneficiary Designation Form

To designate a beneficiary for the Death Benefit, you must fill out this form and return it to the Fund Office.

Dependent Affidavit Form

If you are not married to your natural child’s mother/father, then you need to complete this form, have it notarized, and submit it to the Fund Office with any supporting documents.

Initial Report of Claims

If your provider does not automatically submit your bill to the Fund office, Wilson-McShane Corporation, please complete this form and return it to the Fund Office with the appropriate itemized bills.

Subrogation Agreement

Complete this form to acknowledge the Fund’s subrogation and reimbursement interests. For more information, please contact the Fund Office.

Initial Disability Form

If you become disabled and are unable to work, you and your physician must complete this form and submit it to the Fund Office, in order to receive the weekly disability benefits.

Supplementary Disability Form

Once approved for the weekly disability benefit, you will be responsible to periodically complete this form and submit it to the Fund Office to continue to receive the weekly disability benefit.

Reciprocity Form

If you’re a member of a participating local in the Heartland Healthcare Fund and are working outside of the Heartland locals' jurisdiction, you must complete this form to have your contributions transferred back to the Heartland Healthcare Fund.

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Summary Plan Description (SPD)

The Summary Plan Description explains the benefits available to you and your family. When reading the SPD, please also be sure to read the Summary of Material Modifications (SMM) as they will explain the most recent Plan changes.

Regular Plan Summary of Benefits and Coverage (SBC)

This document provides you with a quick reference of covered expenses, deductibles and out-of-pocket. This is not a full explanation of the benefits covered by the Plan. For more information about the benefits covered by the Plan, please reference the Summary Plan Description.

Reduced Plan Summary of Benefits and Coverage (SBC)

This document provides you with a quick reference of covered expenses, deductibles and out-of-pocket costs for the Reduced Plan. This is not a full explanation of the benefits covered by the Plan. For more information about the benefits covered by the Plan, please reference the Summary Plan Description.

Pre-Apprentice Plan Summary of Benefits and Coverage (SBC)

This document provides you with a quick reference of covered expenses, deductibles and out-of-pocket costs for the Pre-Apprentice Plan. This is not a full explanation of the benefits covered by the Plan. For more information about the benefits covered by the Plan, please reference the Summary Plan Description.

Summary of Material Modification (SMM)

The Summary Plan Description document is updated from time-to-time. SMM include additional information and changes to the Plan.

SMM - SaveOnSP Program

The Summary Plan Description document is updated from time-to-time. SMM include additional information and changes to the Plan.

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Notice of Creditable Coverage

This Notice provides confirmation that the Fund provides creditable prescription drug coverage and is important for participants who are currently eligible or soon to be eligible for Medicare Coverage.

Summary Annual Report (SAR)

The Summary Annual Report provides insurance and basic financial information regarding the Plan and informs you of your rights to additional information.