Wednesday, March 19, 2025

Health Care Documents

Recent Mailings
Recent Mailings
EPT & Virta Health Program
Notice Non-Discrimination Section 1557
2025 Humana Advantage Plan Rate Change
2023 EPT Summary Annual Report (SAR)
2024 Summary of Benefits & Coverage-Aetna Non-Medicare Retirees
2024 Summary of Benefits & Coverage-Kaiser Floor Coverers Early Retirees
2024 Summary of Benefits & Coverage-Kaiser Gypsum HW Retirees
2024 Summary of Benefits & Coverage-Aetna Actives
2024 Summary of Benefits & Coverage-Aetna Residential
2024 Summary of Benefits & Coverage-Kaiser Glaziers L740
Creditable Coverage Notice 2024
EPT Monthly Status Slip Discontinuance Notice
Canopy EAP Benefit (Spanish)
Canopy EAP Benefit
EPT New Mobile Application
Maternity Leave Program Info
Assignment of Rights Change Notice - Effective August 1, 2020
Pre-Retirement Notification
OxyContin Appeal Letter
Forms
Forms
VSP OON Reimbursement Form
Disability Cover Letter & Application
Spanish EPT Beneficiary Form
Spanish EPT Enrollment Packet Forms
Spanish EPT Enrollment Form
Spanish EPT PHI Form
Aetna Reimbursement Form
LMCI Maternity Leave Application
Spanish Disability Cover Letter & Application 2021
Injury Detail Form 2022
Coordination of Benefits Form 02-04-2021
Voluntary Termination Request Form - Dependent Spouse
Voluntary Termination Request Form - Dependent Under Age 18
Voluntary Termination Request Form - Dependent Over Age 18
Enrollment Form
Address Change Form
Beneficiary Designation Form
PHI Authorization for Release of Protected Health Information
Vital Information Form
Amendments and Changes
Amendments and Changes
SMM - Delta Dental eff 1.1.2025
SMM - Genetic & Pharmacogenomic Testing
SMM - Surrogate_ Out of Country Coverage_Stepchildren Eff 6/1/2024
SMM - Prosthodontic Services In-Network OR ONLY Eff 5/1/2024
SMM - Naloxone OTC Eff 2/1/2024
Balance Billing Notice
Documents / Summary Plan Description
Documents / Summary Plan Description
VSP Benefit Summary 2025
EPT Delta Dental Benefit Summary
EPT Delta Dental FAQ
Summary Plan Description (SPD) - 2023 Spanish Version
2023 Summary Plan Description (SPD)