Application for Retiree Health and Welfare Coverage - This form is used to apply for Retiree Health and Welfare Coverage.

RX America Mail Order Brochure - Use this form to order prescription drugs or refills.

Enrollment Card - Use this card for initial enrollment or to report changes to dependent status. Note: Dependents are generally eligible if enrolled when you first enroll, or within 30 days of marriage, domestic partnership, birth, adoption, etc. If not, you must wait until the Plan's open enrollment period, unless you have delayed enrollment under the Plan's Special Enrollment provision.

Application for Early Retiree Membership - Use this form to apply for early retiree membership.

Declaration of Domestic Partnership For Enrollment and Eligibility - Coverage for the Domestic Partner will begin on the first day of the following month upon submission of the fully executed and notarized original of this form (please keep a copy for your records).

Death Benefit Claim - Use this form to claim death benefits. A certified copy of the official death certificate must be attached and sent to the Trust Fund Office.

Retail Prescription Drug Card Program - San Francisco Electrical Workers and RxAmerica are pleased to provide the retail and mail order prescription program to the self-funded indemnity plan. Please review the following information provided to help you best utilize the pharmacy program.

Participant Authorization Form - Use this form to disclose health information in the manner deemed necessary by the Health Plan in compliance with applicable law.

Request For Restrictions On Use and/or Disclosure Of Protected Health Information - Request a restriction on the San Francisco Electrical Workers Health & Welfare Plan’s (Health Plan) use and/or disclosure of your health information.

Participant Request For Confidential Communications - Use this form to request that the Health Plan communicate with you in the alternative manner and/or location regarding health information.

Request for Access to Protected Health Information - Request a copy of health information from the San Francisco Electrical Workers Health for specific dates.

Application for Temporary Health & Welfare Coverage - Use this form to apply for temporary disability Health & Welfare coverage.

Disability Claim Notice - This claim form is used to apply for disability claims.

Physician's Statement of Disability - This form is used to determine long-term disability coverage and must be completed by a licensed doctor.

Medical Extension Form Attending Physician's Statement - This form must be completed by an attending physician in order to extend long-term disability coverage past the 13th month.

Long Term Disability - Use this form to apply for a maximum 6-month extension for long-term disability coverage.

Notice of Privacy Practices - This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Summary of Continuation Coverage Rights Under COBRA and State Law - This notice contains important information about your right to purchase COBRA continuation coverage, which is a temporary extension of health coverage under the Plan.

Summary of USERRA Rights - The following represents a summary of the rights afforded to Plan Participants who are ordered to active military service (USERRA Rights) as they relate to the Northern California Electrical Workers Pension Trust and the San Francisco Electrical Workers Health & Welfare Plan.

Clinical Management Services - This Notice Applies to Indemnity Plan Participants Only, not to Kaiser or PacifiCare Members.

Member Assistance Plan - San Francisco Electrical Workers Trust Fund is pleased to offer a Member Assistance Program (MAP) benefits to ALL its’ members, insured dependents and their household members. It is provided by PacifiCare Behavioral Health (PBH).

Schedule of Transplant Benefits (Indemnity Plan Only) - The following schedule summarizes coinsurance amounts paid by the plan, benefit maximums and additional explanations needed for your transplant benefits. Please refer to the text for additional plan provisions which may affect your benefits.

The First Health National Transplant Program (Indemnity Plan Only) - First Health NationalTransplant Program is a coordinated set of transplant services provided through a special network of transplant facilities. It is designed to help you obtain the transplant services that are appropriate for you and eligible for reimbursement under this plan.

2007 Medical Plan Information: Active - This is the Open Enrollment Package for 2007 containing the open enrollment information as well as the new Health Summary Plan Description. Open enrollment remained open through July 27, 2007.  Changes took effect on August 1st, 2007.

2007 Medical Plan Information: Retiree - This is the Open Enrollment Package for 2007 containing the open enrollment information as well as the new Health Summary Plan Description. Open enrollment remained open through July 27, 2007.  Changes took effect on August 1st, 2007.

Summary Annual Report - Plan Year Ending 1/2007 - This is the Summary Annual Report for the Plan year ending January 31, 2007.

Summary Annual Report - Plan Year Ending 1/2006 - This is the Summary Annual Report for the Plan year ending January 31, 2006.

Summary Annual Report - Plan Year Ending 1/2005 - This is the Summary Annual Report for the Plan year ending January 31, 2005.

Women's Health and Cancer Rights Act of 1998 - On October 21, 1998, President Clinton signed the Omnibus Appropriations Bill which included a new federal law called the Women's Health and Cancer Rights Act of 1998.