Locals 302 and 612 of the International Union of Operating Engineers Trust Funds

Forms

Claim Forms

Dental Claim Form
Medical/Time Loss Claim Form
Notice of Appeal
Authorization for Provider Appeal (For a Provider making an Appeal on the Member's behalf)
OptumRx Reimbursement Form
OptumRx PDP Reimbursement Form

Retirees

VSP Out-Of-Network Reimbursement Form

Enrollment

Enrollment/Beneficiary Form
Change of Address Form

Disclosure and Privacy

Authorization for Disclosure of Protected Health Information
Revocation of Protected Health Information Disclosure
Notice of Privacy Practices

Health & Security Trust

Notice of Privacy Practices

Dental

Preauthorization

Inpatient admissions and selected outpatient services require preauthorization. The plan will not pay for any hospital stays which are not medically necessary.

For pre-authorization, please call:
First Choice: (800) 986-9156
Behavioral Health (BHCC): (800) 640-7682

Where to send completed Medical, Dental and Time-Loss Claim forms

LOCALS 302/612 HEALTH TRUST
P.O. Box 34684
Seattle, WA 98124-1684

Mail All Other Completed Forms

Administration Office
P.O. Box 34203
Seattle, WA 98124-1203