Member Enrollment/Change Form PO Box 300019 Kansas City, MO

Member Enrollment/Change Form
PO Box 300019 Kansas City, MO 64130
I. MEMBER INFORMATION
___________________________________________________________
Name of Member (Last)
(First)
Street Address
City
Local Number
______/______/______
(M.I.)
Date of Birth
State
Zip Code
________-________-_______
(
Social Security Number
)
Telephone #
Employer
Email Address: _____________________________________________________________
 Check if this is a new mailing address
 Check if this is new email address
Sex:
 Male
 Female
Employment Status:  Retired
Marital Status (check one):  Married
 Single
 Divorced
Date of Marriage: ___________/___________/___________
Name of Spouse’s Employer:
__________________________________________________
 check here if spouse is not employed
 Active
 Widowed
Date of Divorce (if applicable): __________/__________/_________
(If children are involved, a copy of the decree is required to
determine medical responsibility.)
II. BENEFICIARY INFORMATION
I designate the following Beneficiary (ies) to receive any benefits which may be payable to my designated Beneficiary under the following Plan: Mo-Kan
Sheet Metal Workers Welfare Fund.
Beneficiary Information
1. _________________________________________
Full Name
--
Street Address, City, State, Zip
--
(
Social Security Number
)
Full Name
/
Date of Birth
Relationship to member
_______________________________________________________
 Primary  Secondary
Street Address, City, State, Zip
--
(
Social Security Number
)
/
Phone Number
3. _________________________________________
Full Name
--
/
Phone Number
2. _________________________________________
--
_________________________________________________________________  Primary
(Select One)
/
Date of Birth
Relationship to member
_______________________________________________________
 Primary  Secondary
Street Address, City, State, Zip
--
Social Security Number
(
)
Phone Number
/
(Select One)
/
Date of Birth
Relationship to member
X Member Signature: ________________________________________________Date:______________________________________________
(REQUIRED)
Important Beneficiary Information:
1.
Your Beneficiary is the person you, as a covered member, designate to receive benefits from the Fund offices should you die. This person would receive any benefits due from life insurance and the Health
and Welfare Fund.
2.
The Primary Beneficiary is the person you wish to receive any benefits due first. If more than one Primary Beneficiary is designated, settlement will be made in equal shares to such of the designated
beneficiaries as survive you, unless otherwise provided herein.
3.
The Secondary Beneficiary is the person you wish to receive any benefits should all the Primary Beneficiaries be deceased.
4.
If you fail to designate a beneficiary, or no designated beneficiary survives you, payment will be made to your Estate, or as otherwise provided in the applicable Plan Document.
5.
If the beneficiary named is a minor(s) or is otherwise incapacitated, Guardianship or Conservatorship of the Estate of the minor(s) or incapacitated person must be submitted at the time of claim to release
any amount payable to the named beneficiary.
6.
If a trust is designated as your beneficiary, our offices will require a copy of the trust document.
7.
Please check your beneficiary designation periodically and update your file to reflect your current status (Please note: This information cannot be given out over the phone). The most recent beneficiary
designation on file at the time of your death will control.
This Beneficiary Designation supersedes any previous or current Beneficiary Designation on file.
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Mo-Kan Sheet Metal Workers Welfare Fund
III. SPOUSE / DEPENDENT INFORMATION
Please check appropriate box:
 NEW ENROLLMENT: List your spouse plus all eligible dependents and eligible handicapped children. (PLEASE PRINT)
 ADD / CHANGE DEPENDENT INFORMATION
Please include a copy of any court document, such as a divorce decree or QMCSO
that pertains to medical coverage for your dependent(s).
IMPORTANT 
Spouse
Dependent
Dependent
Dependent
Date of Birth
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
Sex
 Male  Female
 Male  Female
 Male  Female
 Male  Female
Last Name
First Name
Relationship to
Member



Spouse
Dependent Child
Step-Child
Guardian Child



Dependent Child
Step-Child
Guardian Child



Dependent Child
Step-Child
Guardian Child
_____--_____--_____
_____--_____--_____
_____--_____--_____
_____--_____--_____
Are you employed?
 Yes  No
 Yes  No
 Yes  No
 Yes  No
If yes, does your
employer offer
insurance coverage?
 Yes  No
 Yes  No
 Yes  No
 Yes  No
Social Security Number
Address (if different
from member)
Check One
Do you have any
insurance coverage
other than MO-KAN?
Check One
Check One
Check One
 No. Skip to the next
 No. Skip to the next
 No. Skip to the next
 No. Skip to the next
 Yes. Complete the rest of
 Yes. Complete the rest of
 Yes. Complete the rest of
 Yes. Complete the rest of this
dependent.
this column.
dependent.
this column.
dependent.
this column.
dependent.
column.
Name of Other
Insurance Carrier
Effective Date of Policy
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
Other Insurance
Phone Number
Policyholder’s Name,
DOB and Relationship
to Member
Policy Number
Check all that applies.
Coverage Type
 Medical Dental
 RX
Vision
 HRA  HSA
Check all that applies.
Check all that applies.
Check all that applies.
 Medical Dental
 RX
Vision
 Medical Dental
 RX
Vision
 Medical Dental
 RX
Vision
DECLARATION STATEMENT
I hereby declare under penalty of perjury that the information on this form is correct and complete to the best of my knowledge. If requested by the
Fund, I agree to obtain and furnish a copy of any divorce decree, support order or other relevant document. I understand that if any incorrect or
misleading information on this form results in a loss to the Fund, the Fund is entitled to recover the amount of such loss from me or by withholding
from my future benefits.
X Member Signature _____________________________________________________________
DATE ______________________________________
(REQUIRED)
ease Protected Health
IMPORTANT: Review General Authorization Section IV on Next Page
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Mo-Kan Sheet Metal Workers Welfare Fund

IV. *Health Insurance Portability and Accountability Act of 1996
Important Instructions: Completion of this form allows us to release your protected health information (PHI) to individual(s) you specify. If you do not complete this
form, we cannot disclose the information on anyone other than yourself. NOTE: This does not apply to unemancipated children (children under age 18 in MO and
IL). By completing and signing this form, I am authorizing the Fund to release all health information concerning me for purposes of all usual operations of
the Fund including, but not limited to, claim status, questions regarding claim payment, benefits, eligibility, or disability, to the person(s) I have
designated. This authorization is intended to be in addition to, and not restrictive of, any other consent or authorization I have given, or may give, to the
Fund concerning my health information.
MEMBER: HIPAA GENERAL AUTHORIZATION
Member: ___________________________________________
Member ID (SSN): __________________________________
Person(s) to whom release can be made:
Relationship to Member:
1. ___________________________________________________________________________________________________________
2. ___________________________________________________________________________________________________________
3. ___________________________________________________________________________________________________________
__
Signature of Member or Personal Representative*
Date
Expiration Date (Optional)
This Member Authorization will remain in effect for one year after termination of coverage unless otherwise specified above.
SPOUSE:
HIPAA GENERAL AUTHORIZATION
DEPENDENTS OVER 18
: HIPAA GENERAL AUTHORIZATION
Spouse Name:
Spouse ID (SSN):
Dependents Name:
Dependents ID (SSN):
Person(s) to whom release can be made and relationship to Spouse.
Person(s) to whom release can be made and relationship to Dependent.
1.
1.
2.
2.
3.
3.
Signature of Spouse or Personal Representative and Date
Signature of Dependent or Personal Representative and Date
Expiration Date (Optional)
Expiration Date (Optional)
This Spousal Authorization will remain in effect for one year after
termination of coverage unless otherwise specified above.
This Dependents Authorization will remain in effect for one year after
termination of coverage unless otherwise specified above.
Important Information Concerning Your Rights:
1.
2.
3.
4.
5.
You may revoke this Authorization at any time. However, any revocation will not apply to the extent any action that the Fund may have already taken in reliance
upon your Authorization. Your request for revocation must be in writing. A Revocation of Authorization Form is available at the Fund Office and will be provided
upon request.
We may not condition the provision of treatment, payment, enrollment in health plan, or eligibility for benefits upon your signing this Authorization. However, the
Plan cannot release PHI to unauthorized individuals.
Information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and may no longer be protected by Federal health
information privacy laws.
You may receive a copy of any signed Authorization received by our office, upon request.
You may refuse to sign this Authorization. You have the right to inspect or copy the protected health information to be disclosed under this Authorization.
*If signed by a legally authorized Personal Representative of the member or spouse, you must provide the printed name of the Personal Representative and a
description of the Personal Representative’s authority to act on behalf of the individual: ____________________________________________________________
__________________________________________________________________________________________________________________________________
Please Note: If a Power of Attorney has been signed, please furnish a copy of the Power of Attorney document.
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Mo-Kan Sheet Metal Workers Welfare Fund