Spotlight on Benefits Newsletters

Volume 16, Number 1

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

Volume 11, Number 3

Winter 2003

Volume 11, Number 2

Summer 2003

Health Plan Documents and Forms 

July 1, 2003 Health Plan Booklet

Describes the benefits offered through the DGA-Producer Health Plan.

Health Plan Booklet Updates

Details changes made to the DGA-Producer Health Plan since the publication of the July 1, 2003 Health Plan Booklet.

ACH (Bank Debit) Form

This form directs the Health Plan to withdraw your dependent premium or self-pay premium directly from your bank account.

Change of Address Form

Please file the Change of Address form with the Plans whenever you move.

Credit Card Form

This form directs the Health Plan to charge your dependent premium or self-pay premium to your credit card. 

Dependent Enrollment Form

This form must be submitted to the Health Plan when enrolling new dependents under your health coverage.

Dental Plan Claims Form

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.

HCFA-1500 Form

When you submit a non-network outpatient mental health claim to PacifiCare Behavioral Health, the Health Plan's mental health benefit manager, this form must be filled out and be accompanied by an itemized bill with diagnoses and payment sheets.

Health Plan Claims Form

When you visit a non-PPO (out of network) provider, this form must be filled out and be accompanied by an itemized bill with diagnoses and payment sheets. If you visit a PPO (in-network) provider, the doctor will take care of the paperwork.

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.

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.

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 (Note: the link will take you to the New York State Insurance Department Web site).

Prescription Drug Claims Form

When you obtain prescription drugs from a non-Medco 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 Medco for partial reimbursement. If you visit a Medco pharmacy, there is no paperwork.

Student Verification Form

This form must be submitted to the Health Plan on a semi-annual basis in order to confirm the full-time student status of your dependents ages 19-22. 

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.

VSP Out of Network Reimbursement Form

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.

Pension Plan Documents and Forms

January 1, 2001 Pension Plans Booklet

Describes the benefits offered through the DGA-Producer Pension Plans.

Pension Plan Booklet Updates

Details changes made to the DGA-Producer Pension Plans since the publication of the January 1, 2001 Pension Plans Booklet.

Basic Plan Direct Deposit Form

If you are receiving a monthly pension benefit from the DGA-Producer Basic Pension Plan, this form allows you to have the benefit amount deposited directly into a bank account.

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.

Change of Address Form

Please file the Change of Address form with the Plans whenever you move.

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 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.

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.