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.

Retiree Health Plan Beneficiary Benefit Form (Retiree Only) - Use this form to designate the beneficiary(ies).

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.

Retiree Health Plan - Premium Reimbursement Policy Information (Retiree Only) - Use this form to submit information for Premium Reimbursement. Be sure to include all the required documentation when submitting it to the Trust.

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 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.

Kaiser Permanente - Early Retiree Reimbursement Claim Form for Copayment Refund - Use this form to submit your claim for reimbursement of the copayments incorrectly charged by Kaiser Permanente on brand name prescription medications.

Retiree Health Plan Premium Reimbursement (Retiree Only) - Use this form to submit your claim for reimbursement for private medical coverage.

Retiree Health Plan Medicare Supplement Reimbursement (Retiree Only) - Use this form to submit your claim for reimbursement after Medicare and any other group insurance plans have adjudicated the claim.

HIPAA Special Enrollment (Retiree Only) - Use this form to DECLINE. An eligible retiree or spouse may decline initial enrollment in the RHP in the event the retiree or spouse may decline initial enrollment in the Retiree Health Plan in the event the retiree or spouse is declining initial enrollment due to other coverage. Please review and contact the Fund Office for assistance.

HIPAA Special Enrollment (Retiree Only) - Use this form to ENROLL during the HIPAA Special Enrollment (only if you or your spouse declined initial enrollment due to other coverage. Please review and contact the Fund Office for assistance.

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

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.

Retiree Health Plan Application (Retiree Only) - Use this application to apply for health coverage during retirement. A determination on eligibility will be made following receipt by the Fund Office of the completed application.

Family Account Change Form (Retiree Only) - Use this form to add or remove a spouse from Medical coverage.

Medical Care Enrollment Form/Early Retirees - Use this form to enroll yourself and your spouse in a Medical Plan.

Medical/Dental/Vision Coverage Enrollment Form/Disability Retirees (Retiree Only) - Use this form to enroll yourself and your spouse in a Medical, Dental and Vision Plan.

Kaiser Permanente/Senior Advantage Election Form (Retiree Only) - If the retiree or eligible spouse selects one of the HMO medical Plans for health coverage and is eligible for Medicare, he or she must assign the Medicare benefits to the HMO Medicare-risk Plan that the retiree or spouse selects. Please contact the Trust Funds Office to obtain the enrollment form for Kaiser Permanente - Senior Advantage.

PacifiCare /Secure Horizons Enrollment Form (Retiree Only) - If the retiree or eligible spouse selects one of the HMO medical Plans for health coverage and is eligible for Medicare, he or she must assign the Medicare benefits to the HMO Medicare-risk Plan that the retiree or spouse selects. Please contact the Trust Funds Office to obtain the enrollment form for Secure Horizons/United Health care.

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.