Heath and Welfare Forms

Click the health and welfare forms below to download and print them from your computer. You will need Adobe Acrobat Reader, a free download.

Title	Type	Description
DISABILITY FORM	LOCAL 371 DISABILITY FORM.pdf	A two-page form. First page is for member's completion and the second page is for doctor's to complete.
SUBROGATION FORM/INJURY INQUIRY	HWW_STATEMENT_SUBROGATION_FORM_0.pdf	SUBROGATION FORM/INJURY INQUIRY
MEDCO DIRECT_COB FORM.pdf	MEDCO DIRECT_COB FORM_0.pdf
FT MEDICARE RX CREDITABLE COVERAGE NOTICE.doc	FT MEDICARE RX CREDITABLE COVERAGE NOTICE.doc
PT MEDICARE RX NON CREDITABLE COVERAGE NOTICE.doc	PT MEDICARE RX NON CREDITABLE COVERAGE NOTICE.doc
DURABLE MEDICAL EQUIPMENT AND SUPPLIES CLAIM FORM.pdf	DURABLE MEDICAL EQUIPMENT AND SUPPLIES CLAIM FORM.pdf
OPTICAL CLAIM FORM	OPTICAL CLAIM FORM
PART TIME BENEFIT OPT OUT AND PLAN SECONDARY NOTICE	part_time_opt_out_form.pdf
FULL TIME BENEFIT SUMMARY INSERT INCLUDING DENTAL SCHEDULE	full_time_benefit_summary_insert.pdf
2011 PART TIME PLAN AFFORDABLE CARE ACT WAIVER NOTIFICATION	2011_pt_plan_waiver_affordable_care_act.pdf