Forms

ENROLLMENT DOCUMENTS

HMO/PPO Enrollment Form If you have been notified that you are eligible for benefits, please print and complete this form. Enrollment forms are accepted at the Administrator's office at Open Enrollment (November 15th through December 15th). NOTE: Submitting an enrollment application is not proof of enrollment. California Residents Only

Benefit Change Request Form Complete this form at Open Enrollment, (November 15th through December 15th), to change benefit plans or add/delete dependent coverage. You must be eligible to enroll in benefits.

PPO Enrollment Form If you live in a State other than California and have been notified that you are eligible for benefits, please print and complete this form. Enrollment forms are accepted at the Administrator's office at Open Enrollment (November 15th through December 15th). NOTE: Submitting an enrollment application is not proof of enrollment. Non-California Residents Only

Life Application/Beneficiary Card All eligible participants are enrolled in Life Insurance. Please print and complete this form to designate a beneficiary.

Waiver of Coverage If you have been notified that you are eligible for benefits, but have decided not to enroll, print and complete. Upon certain conditions you may reserve your and your dependent’s right to enroll at a later date.

All completed forms should be sent to: Musicians Health and Welfare
C/o PacFed Benefit Administrators
1000 N. Central Avenue, Suite 400
Glendale, California 91202

OTHER IMPORTANT DOCUMENTS

HIPAA Privacy Notice This notice describes how medical information about you may be used and disclosed, and how you can get access to this information.

Summary Plan Description Summarized in this booklet are Eligibility requirements which you must satisfy in order to qualify for benefits, the benefit plans themselves, and the procedures for review or appeal of claims. This booklet also provides information about the administration of the Plan and your rights under the law.

Member Self-Reporting Form Print and complete this form to advise the Union and Trust Fund of engagements you have performed. See the information about Member Self-Reporting on this web site or in the Fund’s SPD.