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.).

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.

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

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

• Change of Address Form: Complete this form to change or correct your mailing address, and return it to the Fund Office
• Change of Personal Information Form: Complete this form to change or correct your name, and return it to the Fund Office

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

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.

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

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.

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.

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

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.

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.

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.