Documents and Forms

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Spotlight on Benefits Newsletters
Benefits Bulletin December 2013
Volume 21, Number 3 Fall 2013
Volume 21, Number 2 Summer 2013
Volume 21, Number 1 Spring 2013
Volume 20, Number 3 Winter 2012
Volume 20, Number 2 Fall 2012
Volume 20, Number 1 Spring 2012
Volume 19, Number 4 Winter 2011
Volume 19, Number 3 Fall 2011
Volume 19, Number 2 Summer 2011
Volume 19, Number 1 Spring 2011
Volume 18, Number 4 Winter 2010
Volume 18, Number 3 Fall 2010
Volume 18, Number 2 Summer 2010
Volume 18, Number 1 Spring 2010
Volume 17, Number 4 Winter 2009
Volume 17, Number 3 Fall 2009
Volume 17, Number 2 Spring/Summer 2009
Volume 17, Number 1 Spring 2009
Volume 16, Number 4 Winter 2008
Volume 16, Number 3 Fall 2008
Volume 16, Number 2 Summer 2008
Volume 16, Number 1 Spring 2008
Volume 15, Number 2 Fall 2007
Volume 15, Number 1 Spring 2007
Volume 14, Number 4 Winter 2006
Volume 14, Number 3 Fall 2006
Volume 14, Number 2 Summer 2006
Volume 14, Number 1 Spring 2006
Volume 13, Number 2 Fall 2005
Volume 13, Number 1 Spring 2005
Volume 12, Number 2 Winter 2004
Volume 12, Number 1 Summer 2004

 

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Health Plan Documents and Forms
January 2010 Health Plan Booklet Describes the benefits offered through the DGA-Producer Health Plan
Health Plan Booklet Updates Describes changes made to the DGA-Producer Health Plan since the January 2010 booklet was published.
Change of Address Form Please file the Change of Address form with the Plans whenever you move.
Claim Form - Dental When you visit a non-Delta Dental dentist, this form must be filled out and be accompanied by an itemized bill. If you visit a Delta Dental dentist, the dentist will take care of the paperwork.
Claim Form - Medical for non-California participants When you submit a professional (non-hospital) medical claim to BlueCard, if charges are not billed in the CMS-1500 format then a partially completed CMS-1500 form must be attached to the itemized bill to identify you to the BlueCard carrier. This version of the CMS-1500 is specially designed for attachment to BlueCard claims. It includes an instruction sheet explaining how to complete the CMS-1500 for BlueCard claims.
Claim Form - Medical for California participants If you are a California participant submitting a professional (non-hospital) medical claim to Anthem Blue Cross and the charges are not billed in the CMS-1500 format, you must complete items 1 through 13 of this form and then either attach your itemized bill or have your doctor complete items 14 through 33.
Claim Form - Prescription When you obtain prescription drugs from a non-Express Scripts pharmacy, you will have to pay the full amount of the purchase to the pharmacy and then fill out this claim form and submit it to Express Scripts, formerly known as Medco, for partial reimbursement. If you visit an Express Scripts pharmacy, there is no paperwork.
Claim Form - Vision When you visit a non-VSP vision provider, this form must be filled out and accompanied by an itemized bill. If you visit a VSP provider, the provider will take care of all of the necessary paperwork.
Coordination of Benefits Form This form is submitted prior to the Health Plan processing claims for you and your dependents to provide the Health Plan with information regarding your other health insurance, if any. This information is required so that we can coordinate benefit payment with your other insurance.
Dependent Enrollment Form This form must be submitted to the Health Plan when enrolling new dependents under your health coverage.
Dependent Premium Deadline Waiver Request Submit this form to the Health Plan to request a waiver that would allow you to submit your dependent premium payment after the 30-day grace period.
Health Plan Benefits
At-A-Glance
A brief summary of the benefits offered by the DGA-Producer Health Plan.
HIPAA Authorization Form This form authorizes the Health Plan to release protected health information on your behalf or on behalf of your dependents to a third party. Please note that you must submit a separate form on behalf of each family member over the age of 18 (signed by that family member) if you wish the Plan to release protected health information to a third party on their behalf. This form does not allow the Plan to release non-health information.
HIPAA Notice of Privacy Practices This details the Health Plan's privacy practices regarding protected health information.
HMO Plan Comparison of Benefits This details the difference between the Health Plan's DGA Choice/Premier Choice coverage and the Health Plan's HMO option.
Life Events Fact Sheets Getting married. Having a baby. Preparing for retirement. These are the moments in life when your benefits matter most. With that in mind, we have developed the Life Events fact sheets to help ensure that you get all of the information that you need regarding how these events will affect your benefits as well as what action, if any, you need to take.
Medical and Dental Election Form California participants can complete and return this form during their open enrollment period to switch from DGA Choice/Premier Choice Plan coverage to the Health Plan's HMO option, or vice-versa.
NY COBRA Assistance Application COBRA self-pay participants who are residents of the State of New York may be eligible to receive assistance in paying a portion of their COBRA self-pay premium from the New York Department of Insurance.  This is the application that must be sent to the State of New York to apply for assistance.
Pension Deduction Authorization Form This form authorizes the Health Plan to collect your health care premium directly from your Basic Plan monthly pension benefit each month. This is only for participants on self-pay coverage (COBRA/self-pay). This option is not available for dependent premium payment.
Summary of Benefits and Coverage An eight page summary including information about covered benefits, cost sharing and exclusions, accompanied by a standard glossary of common insurance and medical terms.
Third Party Authorization Form This form authorizes the DGA-Producer Pension and Health Plans to release non-health related information to a third party (e.g. pension information, contribution information, etc.). Please note that this form does not allow the Plan to release protected health information.

 

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Pension Plan Documents and Forms
November 2009 Pension Plans Booklet Describes the benefits offered through the DGA-Producer Pension Plans.
Pension Plans Booklet Updates Details changes made to the DGA-Producer Pension Plans since the publication of the November 2009 Pension Plans Booklet.
Basic Plan Withholding Form If you are receiving a monthly pension benefit from the DGA-Producer Basic Pension Plan, this form allows you to elect the amount of Federal and State taxes that will be withheld from your monthly pension benefit.
Beneficiary Designation Form This form allows you to designate a beneficiary or beneficiaries to receive your Basic and Supplemental Plan benefits, in the event of your death.
California EDD
Form DE-4P
This is the State of California Employment Development Department Withholding Certificate for Pension or Annuity Payments form.
Change of Address Form Please file the Change of Address form with the Plans whenever you move.
Direct Deposit Form If you would like to have your monthly pension benefit deposited directly into your bank account, please fill out this form and mail it to the Plans office.
Employment Recap Form If you are retired from the Basic Pension Plan and have returned to DGA covered employment, complete this form to provide a recap of your recent employment.
IRS Form W-4P This is the Internal Revenue Service Withholding Certificate for Pension or Annuity Payments form.
IRS Form W-7 This is the Internal Revenue Service Application for IRS Individual Taxpayer Identification Number form.
IRS Form W-8BEN This is the Internal Revenue Service Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding form.
Retirement Application Request Form This is the form requesting a retirement application package from the DGA-Producer Pension Plans. This is not the retirement application.
Supplemental Plan Distribution Request for Post-Retirement Benefits If you have retired from the Supplemental Plan and will be receiving your benefit as a lump sum, complete this form to elect to have all or part of the eligible distribution transferred directly to an IRA or other retirement account, or sent via direct deposit to your bank account.
Supplemental Plan Incoming Rollover Form This form must be submitted to the Pension Plan office if you are planning on rolling funds from a qualified plan into your Supplemental Plan account.
Supplemental Plan Partial Distributions Form - Post Retirement Qualifying participants can use this form to request their lump sum payment from the DGA-Producer Supplemental Plan in partial distributions. If this is your first time requesting a partial distribution, you must first submit a completed Retirement Application Request Form.
Third Party Authorization Form This form authorizes the DGA-Producer Pension and Health Plans to release non-health related information to a third party (e.g. pension information, contribution information, etc.). Please note that this form does not allow the Plan to release protected health information.  

 

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