NORTHERN ILLINOIS AND IOWA LABORERS' HEALTH AND WELFARE TRUST
MEDICAL BENEFITS REQUEST

Employee Information

Employee Name:   
Date of Birth:   Social Security Number: 
Address:  
Sex:  Marital Status: 



Dependent Information

Please Complete for all dependents covered by this request

Dependent Name 

Sex

Relationship to Employee

Date of Birth

Social Security Number

Does Dependent have other Insurance? 
If so, list Insurance Company name


Spouse's Information

Is Spouse Employed?:  Spouse's Employer (Company Name): 
Employer Mailing Address:    
Does your spouse carry family coverage?: 
Does Your Spouse Have Group Medical Coverage through His/Her employer?: 
If Spouse Carries Family Coverage: 

To all Providers of Health Care:

YOU ARE AUTHORIZED TO PROVIDE TO NORTHERN ILLINOIS AND IOWA LABORERS' HEALTH AND WELFARE TRUST FUND AND ANY INDEPENDENT CLAIM ADMINISTRATORS AND CONSULTING HEALTH PROFESSIONALS AND UTILIZATION REVIEW ORGANIZATIONS WITH WHOM THE FUND HAS CONTRACTED, INFORMATION, CONCERNING HEALTH CARE ADVICE, TREATMENT OR SUPPLIES PROVIDED THE PATIENT (INCLUDING THAT RELATING TO MENTAL ILLNESS AND/OR SUBSTANCE ABUSE). THIS INFORMATION WILL BE USED TO EVALUATE CLAIMS FOR BENEFITS. THE FUND MAY PROVIDE THE MEMBER NAMED ABOVE WITH ANY BENEFIT CALCULATION USED IN PAYMENT OF THIS CLAIM FOR THE PURPOSE OF REVIEWING THE EXPERIENCE AND OPERATION OF THE PLAN. THIS AUTHORIZATION IS VALID FOR THE TERM OF THE CLAIM WHICH HAS BEEN SUBMITTED. I KNOW THAT I HAVE A RIGHT TO RECEIVE A COPY OF THIS AUTHORIZATION UPON REQUEST AND AGREE THAT A PHOTOGRAPHIC COPY OF THIS AUTHORIZATION IS AS VALID AS THE ORIGINAL.  


Print Responsible Party Name: 
Signature of Responsible Party (Use mouse, stylus or finger to sign):
 



I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO THE PHYSICIAN OR SUPPLIER OF SERVICE:
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD OR DECEIVE THE FUND, FILES A STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A CRIME AND MAY BE LIABLE FOR SUBSTANTIAL CIVIL PENALTIES.