HIPPA Privacy Notice - The Southern California IBEW-NECA Health Plan may use the limited quantity of private health information available, that is, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), for purposes of making or obtaining payment for your care and conducting health care operations.

Authorization for Use and Disclosure of Private Health Information - Use this form to authorize release of personal health information in order to use the services of HealthAdvocate.

Life and Accidental Death & Dismemberment Insurance/Beneficiary Designation Form (Active Only) - Use this form to designate beneficiary(ies) for Life and Accidental Death and Dismemberment Insurance.

Change of Address - Use this form to change your address. Be sure to fill it out completely and return it to the Trust Office. (English Version)

Forma Para Solicitar Cambio De Dirección (En Español) - Use esta forma para hacer un cambio de dirección postal.  Asegúrese de completar todos los espacios en la forma, y de enviar la misma a la oficina del Trust Funds.

Workers Compensation form (Active Only) - Complete this form for consideration of benefits.

HIPAA Participant Request for Confidential Communications Form - Use this form to authorize use and/or disclosure of protected health information (i.e. submission of a benefits claim form for follow-up with a vendor by the Fund Office).

HIPAA Participant Authorization Form - Use this form to instruct the Fund Office to communicate with you at an alternate address regarding your eligibility, carrier changes, etc.

Dental Claim (Active Only) - You, or your dentist, may use this form to submit dental claims to the Trust.

Orthotic Reimbursement Form (Active Only) - Complete and return this form when seeking reimbursement for covered orthotic expenses.

Prescription Drug Program Direct Member Reimbursement - Complete and return this form when you have purchased a covered prescribed prescription drug at retail cost and are seeking reimbursement.

Health Hours Estimation Request - Use this form to request an estimate of your Health Hours for your Retiree Health Plan application.

Accelerated Benefits Option Claim Form (Active Only) - Use this form to sign up for MetLife's Accelerated Benefits Option for your Group Insurance plan.

Premium Waiver, Continued Life Insurance, and Total & Permanent Disability Form (Active Only) - Use this form to sign up for continued protection (Premium Waiver during a period of total disability), continued life insurance during total disability, or total and permanent disability.

Medical and Dental Plan Enrollment (Active Only) - Use this form to enroll yourself and eligible dependents in a Medical and Dental Plan. Your Plan election will remain in effect until the next Open Enrollment Period.

Health and Dental Plan Family Account Change (Active Only) - Use this form to add or remove a spouse or eligible dependents from coverage in a Health or Dental Plan.

Affidavit and Declaration of Domestic Partnership for Enrollment in the Plan (Active Only) - Use this form to declare a domestic partnership for enrollment in the plan.

HIPAA Special Enrollment Rights for Overage Dependents/Decline Initial Enrollment (Active Only) - Use this form to DECLINE. An eligible overage dependent may decline initial enrollment in the SC IBEW-NECA Health Plan - Active due to other coverage at the time of enrollment. Please review and contact the Fund Office for assistance.

HIPAA Special Enrollment for Overage Dependents/Enroll (Active Only) - Use this form to ENROLL during the HIPAA Special Enrollment (only if the overage dependent declined initial enrollment due to other coverage). Please review and contact the Fund Office for assistance.

Overage Dependent Certification (Active Only) - This form must be completed and signed by the overage dependent and submitted by the participant as part of their request for enrollment of the overage dependent in the Plan. If your dependent child is turning 19, you must also submit this form.

Summary Annual Report - This describes the status of the fund at the end of Plan Year 2010.

Summary Annual Report - This describes the status of the fund at the end of Plan Year 2009.

Summary Annual Report - This describes the status of the fund at the end of Plan Year 2008.

Summary Annual Report - This describes the status of the fund at the end of Plan Year 2007.

Summary Annual Report - This describes the status of the fund at the end of Plan Year 2006.