SEIU Local 2000

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Your medical claim may be denied or your eligibility status pended because we have not received information from you. Please find below a list of forms that you can download, complete and mail back to us so we can update your information:

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CLAIM LETTERS

ACCIDENT OR INJURY FORM
This questionnaire needs to be completed when you had an accident or injury and your medical claim was denied for details of the injury.

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION
We need your writen authorization to allow family members or other individual to have access to your health information. You also have the right to limit the information that the fund release under this authorization. We have to have this form in our files in order to discuss any of your health information.

CLAIM FORM
This form needs to be completed every year by all Participants. You have to complete this form also when we receive a medical claim for your dependent and we need Coordination of Benefits (COB) information on your spouse. We follow the birthday rule (this means that whoever's birthday is earlier in the year will be primary, i.e., if your birthday is April, 4th and your spouse is July 10, you are primary)

HIGH RISK PREGNANCY QUESTIONNAIRE TO BE COMPLETED BY DOCTOR
Form to be completed by doctor to determine if you are considered a High Risk Pregnancy Patient.

HIGH RISK PREGNANCY LETTER TO BE COMPLETED BY MEMBER
Form to be completed by member. This information is required to assist you with Education and
Health programs.

INJECTABLE DRUGS
To be completed by provider.

ORGAN TRANSPLANT
To be completed by participant

PRE-EXISTING INFORMATION REQUIRED BY PROVIDER

PRE-EXISTING INFORMATION REQUIRED BY MEMBER

STUDENT STATUS VERIFICATION FORM
When your children are over 19 years old, we require a letter from the school they are attending verifying that your children are full time students.

SUBROGATION AGREEMENT
If you or your dependent suffer an injury or illness that is caused by the negligence or fault of a third party, it is your obligation to sign this agreement before benefits are paid.

ELIGIBILITY LETTERS

ELIGIBILITY RULES FOR DEPENDENTS

ELIGIBILITY STATUS CHANGE FORM

ORDER OF BENEFITS DETERMINATION