Retiree Health & Welfare
Health & Welfare Plan
Forms & Documents
Three Ways to Submit Completed Forms
- Submit Online: Forms with the e-sign icon () can be filled out and submitted online!
- Upload a Scan: Fill out, print, sign, and then securely upload a scanned copy. Most forms can be easily filled out on your computer. Simply open the file, click into the form field (it may be highlighted), and start typing. Forms filled out on your computer can be printed to sign and then scanned in to upload, using our secure upload area, or they can be mailed, as below.
- Mail to: Operating Engineers Trust Funds, PO Box 7063, Pasadena, CA 91109.
- Change of Address Form
Moved recently? It’s important to keep the Fund informed! Use this form to update your mailing address or your physical address.
You can: fill out online or download PDF form.
- Authorization for Release of Medical Information Form
This form is used to authorize the release of medical information to persons or organizations.
- Appointment of Personal Representative
Authorize your Personal Representative to act for you in receiving any Health and Welfare information (only) that is (or would be) provided to you as a participant/beneficiary of the plan.
- Revoke a Personal Representative
Revoke an existing Personal Representative on file with the Fund.
- Designation of Beneficiary Form
Use this form to designate Primary and Secondary Beneficiary(s).
- Summary of Benefits and Coverage (Operating Engineers PPO Plan)
The SBC shows what this plan covers and what you pay for covered services.
- Summary of Benefits Comparison
Compare the various plan benefits to get a better idea of what your coverage will look like.
- Model Medical Child Support Order (CA)
A model medical child support order for the State of California.
- Model Medical Child Support Order (NV)
A model medical child support order for the State of Nevada.
Health Plan Forms
- Health and Welfare Medical Plan Choice Form
Use this form to request an enrollment packet for the various Medical Plan options available.
- Health and Welfare Medical Plan Change From HMO to PPO for Active Members
Use this form to change from an HMO to a PPO Plan.
- Group Insurance Questionnaire
This is used to inform the Fund of any other medical or dental coverage a Participant or Eligible Dependent might have.
- Health Plan Enrollment Form
Use this form to enroll in the Operating Engineers PPO Plan or to add eligible dependents.
- Health Plan of Nevada Enrollment and Change Form
Use this form to enroll in the UHC Health Plan of Nevada or to add eligible dependents.
- Kaiser Enrollment Form-Change Form
Use this form to enroll in the Kaiser health plan or to add eligible dependents.
- Anthem Medical Claim Form
Use this form if you need to submit a Medical Claim.
- Dental Claim Form
Use this form if you need to submit a Dental Claim.
- Prescription Drug Claim Form
Use this form to submit a Prescription Drug Claim.
Dental, Vision, and Rx Forms
- DeltaCare Enrollment Form
If you wish to enroll in a Dental Plan other than the default Operating Engineers Dental PPO Plan, you must elect one of the other options. Use this form to enroll in the DeltaCare Plan.
- United Concordia Enrollment Form
If you wish to enroll in a Dental Plan other than the default Operating Engineers Dental PPO Plan, you must elect one of the other options. Use this form to enroll in the United Concordia Plan.
- Operating Engineers H&W Dental PPO In-Network Fee Schedule
In-Network Fee Schedule for as of 06/01/2017. Please contact the Fund to ensure the fees listed are still in effect.
- Operating Engineers H&W Dental PPO Out-of-Network Fee Schedule
Out-of-Network Fee Schedule for as of 06/01/2017. Please contact the Fund to ensure the fees listed are still in effect.
- OptumRx Prescription Mail Order Form
This form is used to fill prescriptions and have them shipped by mail.
- OptumRx Formulary
You and your doctor can use the formulary to help you choose the most cost-effective prescription medications. This guide tells you if a medication is generic or brand, and if special rules apply.
- Application for Eligibility Extension due to Disability
Use this form to apply for an eligibility extension due to disability. Your doctor must complete and sign a section of this form.
- Application For One Year Disability Extension Of Eligibility
Use this form to apply for a one year eligibility extension due to disability. Your doctor must complete and sign a section of this form.
- Nevada Weekly Disability Application
The Fund receives an additional contribution on behalf of Southern Nevada employees. This additional contribution funds a Weekly Disability program for eligible participants who worked for Southern Nevada employers. Use this form to apply for the Weekly Disability.
Plan Publications/Legally Required
- New Member Assistance Program (MAP)
Effective 01/01/2022, a new behavioral health program through Carelon Behavioral Health is available with enhanced benefits for members.
- Evidence of Coverage (EOC) for MAP
Combined evidence of coverage and disclosure form for the Member Assistance Program with Carelon Behavioral Health.
- Health & Welfare Benefit Improvements
Plan notice from November 2017 detailing three important benefit improvements.
- Notice of Non-Discrimination and Accessibility Requirements
The full notice of compliance with applicable federal civil rights laws and contact information for the Compliance Officer.
- Non-Discrimination Grievance Procedures
Outlines the grievance procedures for complaints alleging any action prohibited by Section 1557 of the Affordable Care Act (42 U.S.C. 18116) and its implementing regulations at 45 CFR part 92, issued by the U.S. Department of Health and Human Services.
- Women’s Health & Cancer Rights (WHCRA)
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA).
- Children’s Health Insurance Program (CHIPRA)
Information about Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP).
- Creditable Coverage Notice for Medicare-Eligible Participants
If you are currently eligible for Medicare or will become eligible for Medicare in 2022/2023, please read this notice as it contains information about prescription drug coverage made available by your eligibility in the Operating Engineers Health & Welfare Fund and Medicare Part D prescription drug coverage available through Medicare.
- Summary Annual Report for Year Ending June 30, 2022
This is a summary of the annual report of the Operating Engineers Health & Welfare Fund, for the year ending June 30, 2022.
- Notice of Privacy Practices for Protected Health Information
This notice is required by law and describes how medical information may be used and disclosed and how you can get access to this information.