Medical Plan Forms

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

Authorization Form

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

Cancellation of Authorization Form (PDF)

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

Disabled Dependent Certification Form

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 Physician Certification of Disability Form must be completed by both the employee and the dependent's attending physician.

Eligible Dependent Certification Form

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 from the employee, must certify the dependent's eligibility for coverage by completing and submitting this form in addition to the enrollment form.

Medical Claim Form

Medical Claim Form (PDF)

Information and form coming soon.