Wednesday, May 29, 2024

Health Care Documents


Machine Readable Files - In Network
Machine Readable Files - In Network
COMING SOON
Machine Readable File Out of Network
Machine Readable File Out of Network
Out of Network - MRF
Health Care Forms
Health Care Forms
Other Insurance Inquiry
COBRA Continuation Coverage Election Form
Application for Disability Benefit
Application for Death Benefits
Vital Information & Benefit Designation
Authorization for Release of Protected Health Information
Reimbursement Claim Form
Newsletters
Newsletters
Ulliance Member Assistance Program Announcement
End of COVID-19 Emergency Participant Notice
Delta Dental - Good Health, Healthy Smile
Delta Dental - Member Portal
Delta Dental - TeleDentistry March 24, 2020
Humana - Silver Sneakers App 3 27 2020
Summary of Benefits and Coverages
Summary of Benefits and Coverages
2022 Summary of Benefit & Coverage and Summary Annual Report
Summary of Benefits and Coverage 2021
Summary Plan Description
Summary Plan Description
Summary Plan Description January 1, 2020
Non-Discrimation Notice
Health Care Recent Information
Health Care Recent Information
New National Network Outside Michigan Eff 4/1/2022
2022 Summary Annual Report and Summary of Benefit & Coverage
Humana Renewal 2022
No Fault Motorized Vehicles August 2020
No Fault Motorized Vehicles Mailer July 2020
Self Payment Rates for Retirees, Disability and Surviving Spouses
COVID-19
Retiree - Dentemax
SMM - March 2019
Preventative Services
Standard Control Formulary Updates 1-1-2023 1
Performance Drug List - Standard Control 1-1-2023  2
Advanced Control Specialty Formulary Updates 1-1-2023  3
Advanced Control Specialty Formulary 01-2023 4
Documents Translated In Spanish
Documents Translated In Spanish
Vital Form
PHI Form
Dependent Coverage
IBEW Local 17 SPD Eff: 1/1/2020 - Spanish
1st Amendment to SPD - Spanish
2nd Amendment to SPD - Spanish
3rd Amendment to SPD - Spanish
5th Amendment to SPD - Spanish