Friday, May 16, 2025

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
Vital Information & Benefit Designation
Physical Reimbursement Form
Application for Disability Benefit
Application for Death Benefits
Other Insurance Inquiry
COBRA Continuation Coverage Election Form
Student Certification for Dependent Child
Authorization for Release of Protected Health Information
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