Public Documents | UFCW Local 655 Welfare Fund

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	Documents Documents Available Preventive Care Services Preventive Care Services as recommended with an A or B rating by the United States Preventive Services Task Force and preventive care and screenings for women as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. U.S. Preventive Services Task Force Health Resources and Services Administration-Preventive Care and Screenings for Women Summary Plan Description - (2018 Edition) Summary Plan Description is a booklet that describes all benefits provided by the Fund. SPD - 2018 Edition Form Summary Plan Description Amendments Gender Dysphoria Coverage - Effective January 1, 2022 Gene Therapy Exclusion - Effective Nov 1, 2019 Absolute Solutions Radiology Services - Effective Jan 1, 2019 Vision Care Benefits - Effective Jan 1, 2019 Schedule of Benefits - Effective January 1, 2023 The Schedule of Benefits Grid is part of your Summary Plan Description. This pamphlet is a quick reference of benefits that are provided to you through the plan. Rolling Eligibility Schedule of Benefits - Plan A Pamphlet Schedule of Benefits - Plan B Pamphlet Schedule of Benefits - Plan C Pamphlet Schedule of Benefits - Plan D Pamphlet Spanish Versions Rolling Eligibility Schedule of Benefits - Plan A Pamphlet Schedule of Benefits - Plan B Pamphlet Schedule of Benefits - Plan C Pamphlet Schedule of Benefits - Plan D Pamphlet Direct Debit Authorization Forms By completing a direct debit authorization form, you are authorizing UFCW Local 655 Welfare to initiate an ACH direct debit from an account you have supplied. Please note, the member must be the account holder. If you are wanting to submit a One Time Debit, please complete the One Time Direct Debit Authorization Form. If you are no longer with the employer and are wanting to make continuous automated monthly payments, please complete the Direct Debit Authorization Form. Feel free to call our office with any further questions or concerns. One Time Direct Debit Authorization Form Direct Debit Authorization Form How to Submit a Member Paid Claim The Annual Mailing is a group of documents that is important to Eligible Participants of the Fund. How to Submit A Member Paid Claim Form Annual Mailing to Eligible Participants The Annual Mailing is a group of documents that is important to Eligible Participants of the Fund. 2023 Annual Mailing to Eligible Participants Notarized Form Regarding other Insurance for Child Please complete this form in full if you are adding a child to your policy and any of the following are true: You and the natural mother/father were never married. Divorce decree is not available. If there is a guardianship and the natural mother and/or father are ordered to maintain coverage. Notarized Letter Form - 2019 Spanish Version Notarized Letter Form - 2019 Short-Term Disability Form If you miss work due to an illness or injury, a Short-Term Disability Form must be completed. In order to claim Short-Term Disability benefits, you must be eligible for Health & Welfare Benefits at the time of disability. Any injuries or accidents related to work are not covered under Short-Term Disability and must be filed under your employers Worker's Compensation. Short-Term Disability Form Accident Questionnaire An Accident Questionnaire must be completed if the Fund Office receives a claim and the diagnosis could be related to an injury or accident. If you have recently received a denied claim pending for accident information, please complete this questionnaire and submit to the Fund Office for review. Accident Questionnaire Spanish Version Accident Questionnaire Smoker Non-Smoker Change Form If your smoking status has changed since your annual open enrollment, complete this form and submit it to the Fund Office. Smoker Non-Smoker Change Form Spanish Version Smoker Non-Smoker Change Form Spousal Coverage Verification Form A Spousal Coverage Verification Form must be completed if you are adding a spouse to your policy. If your spouse is unemployed or self employed, this form must be notarized and submitted yearly. Spousal Coverage Verification Form Spanish Version Spousal Coverage Verification Form Enrollment and Census Forms Enrollment-Beneficiary Form will allow you to change your election, add/drop spouse and/or dependent child(ren), change beneficiary or address. Enrollment Form Beneficiary Form Authorization for Email Communications Spanish Version Enrollment-Beneficiary Form HIPAA Privacy Information HIPAA Privacy Information is a leaflet to review that explains the Fund's Privacy Practices. HIPAA Privacy Information Spanish Version HIPAA Privacy Information HIPAA Privacy Form This must be completed for anyone over the age of 18 to authorize a representative to speak on their behalf. Enrollment-Beneficiary Form will allow you to change your election, add/drop spouse and/or dependent child(ren), change beneficiary or address. HIPAA Privacy Form for Plan Participant HIPAA Privacy Form for Dependent Children HIPAA Privacy Form for Spouse Spanish Version HIPAA Privacy Form for Plan Participant HIPAA Privacy Form for Dependent Children HIPAA Privacy Form for Spouse Summary of Benefits and Coverage 2025 Summary of Benefits and Coverage - Plan A Summary of Benefits and Coverage - Plan B Summary of Benefits and Coverage - Plan C Summary of Benefits and Coverage - Plan D Summary Annual Report Summary Annual Report for the Fiscal year ending Aug 31, 2021 Summary Annual Report for the Fiscal year ending Aug 31, 2020 Summary Annual Report for the Fiscal year ending Aug 31, 2019 Summary Annual Report for the Fiscal year ending Aug 31, 2018 No Surprises Act No Surprises Act
UFCW Local 655 Welfare Fund 300 Weidman Road, Suite A Ballwin, Mo 63011 Phone: (314)835-2700 The Fund is HIPAA compliant and strives to maintain HIPAA standards and codes. The sole purpose of HIPAA is to improve the access to health insurance and protect private health information. For more information about HIPAA and your rights please visit HIPAA Online which is provided by the United States Department of Health and Human Services. Privacy Policy Privacy Practice Terms of Use Contact Us

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