Monday, February 2, 2026

Health Care Documents

Forms
Forms
Enrollment Application 2020
Disability Form
Summary of Benefits and Coverages
Summary of Benefits and Coverages
2024 Monthly Plan Caring Heart Full Time English and Spanish
2024 Plan D English and Spanish
2024 SBC Monthly Plan - English and Spanish
2024 Hourly Plan Class I English and Spanish
2024 Hourly Plan Class II English and Spanish
2023 Disclosure Notice Regarding Patient Protections Against Surprise Billing
Summary Plan Description
Summary Plan Description
2014 Summary Plan Description (Hourly)-English
2014 Summary Plan Description (Hourly) -Spanish
2014 Summary Plan Description (Monthly)- English
2014 Summary Plan Description (Monthly) -Spanish
Summary Annual Report
Summary Annual Report
ManU Service Contract Trust 2021 Summary Annual Report
Recent Mailing
Recent Mailing
2022 HIPAA Privacy Notice
2022 Mastectomy Notice
2022 Medicare Notice
2022 HIPAA Privacy Notice_Spanish
2022 Mastectomy Notice_Spanish
2022 Medicare Notice_Spanish
SMM#10 Hourly Plan Benefit Enhancement
SMM#10 Monthly Plan Benefit Enhancement
COVID19 Over-the-Counter Test Kits Notice
CVS Caremark OTC COVID Test Paper Claim Form
Amendments
Amendments
No Surprise Act(NSA) Notice
CVS Vaccine Network Notice_English
CVS Vaccine Network Notice_Spanish
2022 Caring Heart Full Time Benefit Changes
SMM #14 Hourly Class I Hospice Benefits
SMM #14 Hourly Class I Hospice Benefits Spanish
SMM #14 Hourly Class II Emergency Room Visit and Hospice Benefits
SMM #14 Hourly Class II Emergency Room Visit and Hospice Benefits Spanish
SMM#16 - Hourly Class I and II Room Board Out of Pocket Maximum Notice