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Home → Welfare Trust → Forms 
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These printable forms are in PDF (Portable Document) format.
To read and print them, you need the free Adobe Acrobat Reader (which is probably already installed in your system). If you do need to install it, click the "Get Acrobat Reader" logo.
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Privacy
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- Privacy Notice - This is the official Privacy Notice of the Plan as required by the HIPAA regulations.
- Release of Health Information - The Health Insurance Portability and Accountability Act of 1996 (HIPAA) protects the health information of each patient. The Alaska Teamster Welfare Trust (the "Plan") is prohibited from releasing protected health information except in very specific circumstances. You have the right to request that the Plan release your protected health information to another party (such as another family member); however, you must provide such permission in writing.
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Announcements & Periodic Reports
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- Summary Annual Report - December 31, 2000 - Describes the status of the fund at the end of Plan Year 2000.
- Summary Annual Report - December 31, 2001 - Describes the status of the fund at the end of Plan Year 2001.
- Summary Annual Report - December 31, 2002 - Describes the status of the fund at the end of Plan Year 2002.
- Summary Annual Report - December 31, 2003 - Describes the status of the fund at the end of Plan Year 2003.
- Summary Annual Report - December 31, 2004 - Describes the status of the fund at the end of Plan Year 2004.
- Summary Annual Report - June 30, 2005 - Describes the status of the fund at the end of Plan Year 2005.
- Summary Annual Report - June 30, 2006 - Describes the status of the fund at the end of Plan Year 2006.
- Summary Annual Report - June 30, 2007 - Describes the status of the fund at the end of Plan Year 2007.
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Required to Receive Benefits
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- Enrollment Form - Used for initial Enrollment or to update changes in your status in the Health Plan; also used as a Claim Form for requesting benefits.
- Beneficiary Designation for Health Plan - Use this form to designate beneficiaries.
- Time Loss Claim Form - Claims form for Health Plan participants.
- Medical Plan Self-Payment Billing Form For Retirees - Coverage form for the Retired Participant.
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Personal Changes
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- Address Change Form - Form for address changes.
- Enrollment Form - Used for initial Enrollment or to update changes in your status in the Health Plan; also used as a Claim Form for requesting benefits.
- Beneficiary Designation for Health Plan - Use this form to designate beneficiaries.
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Brochures
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- HealthTrans Mail Order Pharmacy - Enroll in the HealthTrans Mail Order Pharmacy service. Brochure also contains information and instructions for use.
- HealthTrans Formulary (2008) - List of commonly utilized medications and their generic equivalents for the prescribing physicians.
- HealthTrans Speciality Drug List - Specialty medications are generally utilized for treating unique disease
conditions and are typically injectible or that otherwise require special handling
considerations. Examples of specialty medications are listed in this brochure, but are
not all-inclusive.
- HealthTrans Maintenance Drug List - Maintenance medications are prescribed for chronic, long-term conditions (i.e. diabetes, high-blood
pressure, high cholesterol and seizure disorder). Examples of maintenance medications are found in this brochure.
- Using Your Vision Service Plan Benefit (VSP Flyer) - Vision Service Plan benefits at a glance, information on using your Vision Service Plan benefits, and more.
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COBRA
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- COBRA - Automatic Deduction from Bank Account - This form allows you to elect automatic debit from your checking account to pay the monthly COBRA self-payment.
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Retirees
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- Medical Plan Self-payment Billing Form For Retirees - Coverage form for the Retired Participant.
- Retiree and COBRA Self-payment Rates - Rates for the Retiree Health Plan and COBRA Coverage.
- Eligibility for Retired Participant - Lists Retiree Health Plan eligibility requirements for the Retired Participant.
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Dependent
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- Statement of College Enrollment - Confirm college enrollment of a dependent.
- Statement of Support - Form confirming support of your children or step-children.
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Legally Required
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- Summary Annual Report - December 31, 2000 - Describes the status of the fund at the end of Plan Year 2000.
- Summary Annual Report - December 31, 2001 - Describes the status of the fund at the end of Plan Year 2001.
- Summary Annual Report - December 31, 2002 - Describes the status of the fund at the end of Plan Year 2002.
- Summary Annual Report - December 31, 2003 - Describes the status of the fund at the end of Plan Year 2003.
- Summary Annual Report - December 31, 2004 - Describes the status of the fund at the end of Plan Year 2004.
- Summary Annual Report - June 30, 2005 - Describes the status of the fund at the end of Plan Year 2005.
- Summary Annual Report - June 30, 2006 - Describes the status of the fund at the end of Plan Year 2006.
- Summary Annual Report - June 30, 2007 - Describes the status of the fund at the end of Plan Year 2007.
- Summary Plan Description - This is your benefits booklet known as the Summary Plan Description of the Alaska Teamster-Employer Welfare Trust for active and retired participants. Amendments after January 1, 2007, are not reflected in this file, but can be found in the live SPD here.
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