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Accident-Injury Questionnaire
Complete this questionnaire if you and/or your dependent have been involved in an accident where an injury required medical attention.
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Authorization for Direct Debit
Complete this form to authorize the Plan to debit your checking or savings account for your monthly health and welfare premium. Please note: If you are making Minimum Difference payments, you are NOT eligible for the Direct Debit Option.
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Beneficiary Designation Form
Complete this form to designate a person (or persons) to receive benefits that may be payable upon your death. Important: If beneficiaries are not designated as either primary or secondary, all beneficiaries are considered to be primary by default.
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Certification Form for Adult Child Coverage
Complete this form, in addition to other necessary enrollment forms, for adult children ages 19 up to 26 who are not eligible for health care coverage under their own or their spouse's employer-sponsored health plan.
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Credit Card Authorization Form
Complete this form to authorize monthly credit card installment payments for Carpenters' Health and Welfare Trust Fund contributions.
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Dental Enrollment Form - Self-pay
Complete this form to enroll in the dental/vision portion of the Carpenters' Plan if you are a non-active monthly self-pay participant.
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Enrollment Form
Complete this form to provide information about you and your eligible dependents. Then, send it to the St. Louis Benefit Plans Office so benefits can be processed. This form must be completed and submitted any time family information changes.
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H & W Pension Deduction Authorization Form
Complete this form to authorize the Plan to deduct your monthly health and welfare premiums from your pension benefit.
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HIPAA Form - Dependent Child Age 18+
Dependent children age 18 and older complete this form to authorize the St. Louis Benefit Plans Office to release their personal health information to the individuals listed on the form.
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HIPAA Form - Member and Spouse
Complete this form to authorize the St. Louis Benefit Plans Office to release personal health information to individuals listed on the form. To be completed by both the member and spouse.
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Medco Claim Form
Complete this form to submit prescriptions to Medco for reimbursement when a non-network pharmacy is used or to coordinate benefits when another prescription plan has already paid their portion of the prescription bill.
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Medco Mail Order Form
Complete this form to submit prescriptions to Medco for mail-order delivery.
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Signature Specialists List
Download this list of Signature Medical Group Specialists.
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Spousal Coverage Verification Form
Complete this form to provide the Plan with insurance coverage information for both a working and non-working spouse in order to be eligible for coverage.
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VSP Reimbursement Form
Complete this form to submit a request for out-of-network claim reimbursement to VSP for eye care charges incurred at a non-VSP provider.
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Weekly Sickness & Accident Form
Both the Member and Physician must complete this form in order for the member to be consideered for weekly benefits due to a non work-related accident/illness.
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