Forms

This page provides a description of and links to National IAM Benefit Trust Fund forms. Click the form titles in the table below to review or download copies.

FormDescription

Authorization Form (PDF)

Participants in a Benefit Trust Fund medical plan can authorize the Fund to disclose the participant's Protected Health Information to designated individuals. Complete and submit this form to provide such authorization.

Cancellation of Authorization Form (PDF)

If a participant in a Benefit Trust Fund medical plan has authorized the Fund to disclose the participant’s PHI but no longer wishes the Fund to do so, the participant must complete and submit this form.

Dental Claim Form (PDF)

When visiting an out-of-network dentist, be sure to bring a dental claim form. After you and your dentist fill out the form, submit it directly to Delta Dental.

Disabled Dependent Certification Form (PDF)

Eligible employees wishing to designate an eligible disabled dependent must complete and submit this form in addition to the enrollment form.

The second page, Physician Certification of Disability, must be completed by both the employee and the dependent's attending physician.

Eligible Dependent Certification Form (PDF)

Eligible employees who designate eligible dependents who are not the employees’ biological children, or who have a different last name than the employee, must certify the dependent’s eligibility for coverage by completing and submitting this form in addition to the enrollment form.

Enrollment Form (PDF)

Eligible employees may enroll in a National IAM Benefit Trust Fund health plan by completing and submitting this form. This form is also used to enroll eligible dependents. The Fund requires only one enrollment form for all benefit plans under which you and your eligible dependents may be covered (including medical, dental, vision, short-term disability, and life and accidental death and dismemberment benefits).

Medical Claim Form (PDF)

In some cases, medical providers may require participants to submit a medical claim on their own. To submit a medical claim, download and fill out the Medical Claim Form and send it to CIGNA. Detailed instructions are on the Form.

Short-Term Disability Claim Form (PDF)

To submit a disability claim, have a Short-Term Disability Claim Form completed by your employer, yourself, and your physician. Send your completed claim form to the Fund Office for processing.

Vision Claim Form (PDF)Use this form only for claims through December 31, 2015.

After receiving vision care services before January 1, 2016, complete a Vision Claim Form. Submit the completed form to the Benefit Trust Fund along with the itemized receipt from your vision care provider.

Waiver Form (PDF)

Eligible employees wishing to waive coverage must complete and submit this form.

 

 

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Find and download important forms relating to the Benefit Trust Fund health plans.