This page provides a description of and links to National IAM Benefit Trust Fund forms related to Fund medical plans. Click the form titles below to review or download copies.
- Authorization Form
-
Participants in a Benefit Trust Fund medical plan can authorize the Fund to disclose the participant's Protected Health Information to designated individuals. Complete and submit this form to provide such authorization.
- Cancellation of Authorization Form
-
Cancellation of Authorization Form (PDF)
If a participant in a Benefit Trust Fund medical plan has authorized the Fund to disclose the participant's PHI but no longer wishes the Fund to do so, the participant must complete and submit this form.
- Disabled Dependent Certification Form
-
Disabled Dependent Certification Form (PDF)
Eligible employees wishing to designate an eligible disabled dependent must complete and submit this form in addition to the enrollment form. The Physician Certification of Disability Form must be completed by both the employee and the dependent's attending physician.
- Eligible Dependent Certification Form
-
Eligible Dependent Certification Form (PDF)
Eligible employees who designate eligible dependents who are not the employees' biological children, or who have a different last name from the employee, must certify the dependent's eligibility for coverage by completing and submitting this form in addition to the enrollment form.
- Enrollment Form
-
Eligible employees may enroll in a National IAM Benefit Trust Fund medical plan by completing and submitting this form. This form is also used to enroll eligible dependents.
- Medical Claim Form
-
In some cases, medical providers may require participants to submit a medical claim on their own. To submit a medical claim, download and fill out the Medical Claim Form and send it to CIGNA. Detailed instructions are on the Form.
- Waiver Form
-
Eligible employees wishing to waive coverage must complete and submit this form.