Documents and Forms
All forms are in Adobe PDF format. Click here to download the free Adobe Acrobat Reader.
| Spotlight on Benefits Newsletters | |
| 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 |
| 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. |
| Bank Account 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. |
| CMS-1500 Form for OptumHealth | When you submit a non-network outpatient mental health claim to OptumHealth, 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. |
| CMS-1500 Form for BlueCard | 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. |
| COBRA Election Form | This is the form that you send to the Health Plan to elect COBRA self-pay coverage when your earned coverage has expired. |
| 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. |
| 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. |
| 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 | |
| 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 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. |