Complete & Print Forms - You can complete most of the forms listed below right on your computer before you print. Simply click on a field in the form and type in the appropriate information. Then print the completed form, sign and mail it to the Trust Funds Office.
General
HIPPA Privacy Notice (Active Only) - 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.
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 completer todos los espacios en la forma, y de enviar la misma a la oficina del Trust Funds.
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.
Claim Form
Dental Claim (Active Only) - You, or your dentist, may use this form to submit dental claims to the Trust.
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.
Full-Time Student Verification (Active Only) - After the age of 19, your dependent(s) continuity of health coverage is based on being enrolled
in a minimum of 8 units with an accredited college, university or educational institution. Use this form to verify that your student is enrolled and fulfills the unit requirement.