Forms & Documents

General Forms

• 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.
• 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.
• 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.

Claim Forms

• 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.

Disability Forms

• 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.
• Operating Engineers Health & Welfare Fund Trust Agreement
  Agreement and Declaration of Trust establishing the Operating Engineers Health & Welfare Fund