Disability

• Application for Disability Health & Welfare Coverage – Use this form to apply for temporary disability Health & Welfare coverage.
• Long Term Disability Application – This claim form is used to apply for monthly disability claims.
• Physician's Statement of Disability – This form must be completed by a licensed doctor to support an application for Temporary Disability and/or Long Term Disability benefits.
• Application for 6-month Extension of Long Term Disability Benefits – Use this form to apply for a maximum 6-month extension for long-term disability coverage.
• Medical Extension Form Attending Physician's Statement – This form must be completed by an attending physician in order to extend long-term disability coverage past the 13th month.

General

• New NWPS Health Reimbusement Website and Mobile app – NWPS is excited to announce a new NWPS Health Reimbursement website and addition of a Mobile App available on October 16, 2024.
• Pregnancy Leave Benefit Clarification – This Notice clarifies the conditions for receipt of the SFEW Health & Welfare Plan's Supplemental Parental Leave benefits, with updated eligibility rules commencing, effective June 1, 2023.
• Pregnancy Leave Benefit Application – Complete this form and return it to EISB to claim Pregnancy Leave Benefits as described in the Plan document and Summary Plan Description.
• Leave Benefits and Long Term Disability Benefit – Emergency Leave Benefit, Pregnancy Leave Benefit and Long Term Disability Benefit.
• Coverage for Over-the-Counter (OTC) At-Home COVID-19 Test Kits – Under a new federal mandate, your plan covers OTC at-home COVID-19 tests. Find out which tests are covered, where you can purchase tests at a $0 copay, or how your plan will reimburse you.
• Beat It! – New Employee Assistance Program – The Board of Trustees is pleased to announce that Beat It! will provide Employee Assistance Program services starting November 1, 2020.
• Summary of Material Modification/Important Notice Regarding Temporary COVID-19 Benefit Changes and Teladoc – The Board of Trustees has approved several changes to the Plan to provide some relief in response to the novel coronavirus disease, COVID-19, pandemic ("Coronavirus").
• Teladoc Flyer – Get care when and where you need it through your San Francisco Electrical Workers plan. As a member, you have access to Teladoc's national network of U.S. board-certified physicians, licensed in California. Whenever you need care, Teladoc doctors are available 24/7 by phone or video.
• Health Reimbursement Arrangement (HRA) Claim Form – Use this form to submit a claim for reimbursement from your Health Reimbursement Arrangement (HRA) account.
• Health Reimbursement Arrangement Expenses – Summary of general categories of eligible and ineligible expenses.
• 2018 Benefit Changes – In recent months, the Board of Trustees of the San Francisco Electrical Workers Health & Welfare Plan has approved several changes to the Plan. This notice briefly describes these changes and includes several notices that you should read and keep with your Summary Plan Description booklet.
• Enrollment Form for Active Members – Use this card for initial enrollment or to report changes in enrollment status. Note: Dependents are generally eligible if enrolled when you first enroll, or within 30 days of marriage, domestic partnership, birth, adoption, etc. If not, you must wait until the Plan's open enrollment period, unless you have delayed enrollment under the Plan's Special Enrollment provision.
• Enrollment Form to Add an Adult Child Age 19 Through 25 – An Adult Child age 19 through 25 may be eligible for coverage on the same basis as dependent children under the Plan.
• New Parental Leave Benefit - August 2018 – The new collective bargaining agreement that became effective June 1, 2018, provides for an Employer contribution to the SFEW Health & Welfare Plan to fund a new parental leave "supplemental benefit" that supplements the state-provided California Paid Family Leave (CPFL) benefit to bond with a new child entering the family through birth, adoption or foster care placement.
• Application for Supplemental Parental Leave Benefits – Complete this form if you are eligible to receive supplemental cash payments from the Plan for parental leave.
• Application for Retiree Health and Welfare Coverage – This form is used to apply for Retiree Health and Welfare Coverage.
• Application for Early Retiree Membership – Use this form to apply for early retiree membership.
• Declaration of Domestic Partnership For Enrollment and Eligibility – Coverage for the Domestic Partner will begin on the first day of the following month upon submission of the fully executed and notarized original of this form (please keep a copy for your records).
• Death Benefit Claim – Use this form to claim death benefits. A certified copy of the official death certificate must be attached and sent to the Trust Fund Office.
• Optum Mail Order Form – Use this form for new prescription orders and maintenance refills for home delivery.
• Optum Home Delivery – Benefits of medication home delivery.
• Optum Generics – Five things to know about generic medications.
• Direct Member Reimbursement – Use this form to submit prescription claims pending receipt of your prescription drug card, or in cases when prescription users purchase over-the-counter was reinstated retroactively.
• Subscriber's Statement of Claim – This claim form is for participants in the PPO Self Funded Plan whose providers did not bill the Plan directly. Use this form to apply for reimbursement.
• Health Reimbursement Arrangement – As an eligible Participant with a Health Reimbursement Arrangement (HRA) account, you will be able to use the funds in your account starting January 1, 2019.

HIPAA

• Participant Authorization Form – Use this form to disclose health information in the manner deemed necessary by the Health Plan in compliance with applicable law.
• Request For Restrictions On Use and/or Disclosure Of Protected Health Information – Request a restriction on the San Francisco Electrical Workers Health & Welfare Plan's (Health Plan) use and/or disclosure of your health information.
• Participant Request For Confidential Communications – Use this form to request that the Health Plan communicate with you in the alternative manner and/or location regarding health information.
• Request for Access to Protected Health Information – Request a copy of health information from the San Francisco Electrical Workers Health for specific dates.
• Notice of Privacy Practices – The Plan is required under the Privacy Rule of the Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") to maintain the privacy of your protected health information. This notice details the policy and your rights relating to your protected health information.

Legally Required

• ACA Section 1557 Notice – In compliance with Section 1557 and other federal civil rights laws, we provide individuals the following in a timely manner and free of charge: Language assistance services, Appropriate auxiliary aids and services, and Reasonable modifications.
• Summary of Material Modification/Further Extended Eligibility and Dental Benefit Increase - June 2021 – San Francisco Electrical Workers Health & Welfare Plan Important Notice Regarding Further Extended Eligibility and Dental Benefit Increase
• Summary of Material Modification - Extended Eligibility - February 2022 – Important Notice Regarding Coronavirus-Related Extended Eligibility Maximum and COBRA.
• Your Rights and Protections Against Surprise Medical Bills - January 2022 – Effective February 1, 2022, when you get emergency care or get treated by an outof-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
• Summary of Material Modification/HRA Qualifying Medical Expenses - May 2021 – Important Notice of Changes to Plan Relating to Health Reimbursement Arrangement (HRA) Qualifying Medical Expenses for COVID-19 Personal Protective Equipment.
• Summary of Material Modification/Important Notice of Changes to Plan – Important notice of changes to the Plan relating to expiration of deadline extensions during Coronavirus outbreak period.
• Summary of Material Modification/Early Retiree Eligibility- May 2021 – San Francisco Electrical Workers Health & Welfare Plan Important Notice of Changes to Plan Relating to Early Retiree Eligibility – Rule of 85
• Summary of Material Modification/Important Notice Regarding Extended Eligibility – The Board of Trustees of the San Francisco Electrical Workers Health & Welfare Trust Fund has approved a further extension of eligibility.
• Summary of Material Modification/Important Notice of Changes to Plan Relating to Extension of Deadlines During Coronavirus (09/20) – The Board of Trustees of the San Francisco Electrical Workers Health & Welfare Trust Fund has approved a further extension of eligibility under the Plan in response to the novel coronavirus disease, COVID-19, pandemic ("Coronavirus").
• Amendment Article VIII and Article III ERSD – Amendment to the San Francisco Electrical Workers Health and Welfare Plan.
• Summary of Material Modification/Important Notice of Changes to Plan Relating to Extension of Deadlines During Coronavirus (08/20) – In response to the coronavirus disease COVID-19, the Department of Labor and Department of Treasury adopted emergency regulation that extends eight important filing deadlines that may fall within the "Outbreak Period."
• Summary of Material Modification/Important Notice Regarding Temporary COVID-19 Benefit Changes and Teladoc – The Board of Trustees has approved several changes to the Plan to provide some relief in response to the novel coronavirus disease, COVID-19, pandemic ("Coronavirus").
• Summary of Continuation Coverage Rights Under COBRA and State Law – This notice contains important information about your right to purchase COBRA continuation coverage, which is a temporary extension of health coverage under the Plan.
• Summary Annual Report - Plan Year Ending 1/2023 – This is the Summary Annual Report for the Plan year ending January 31, 2023.
• Summary Annual Report - Plan Year Ending 1/2022 – This is the Summary Annual Report for the Plan year ending January 31, 2022.
• Summary Annual Report - Plan Year Ending 1/2021 – This is the Summary Annual Report for the Plan year ending January 31, 2021.
• Summary Annual Report - Plan Year Ending 1/2020 – This is the Summary Annual Report for the Plan year ending January 31, 2020.
• Summary Annual Report - Plan Year Ending 1/2019 – This is the Summary Annual Report for the Plan year ending January 31, 2019.
• Summary Annual Report - Plan Year Ending 1/2018 – This is the Summary Annual Report for the Plan year ending January 31, 2018.
• Summary Annual Report - Plan Year Ending 1/2017 – This is the Summary Annual Report for the Plan year ending January 31, 2017.
• Summary Annual Report - Plan Year Ending 1/2016 – This is the Summary Annual Report for the Plan year ending January 31, 2016.
• Summary Annual Report - Plan Year Ending 1/2015 – This is the Summary Annual Report for the Plan year ending January 31, 2015.
• Summary Annual Report - Plan Year Ending 1/2014 – This is the Summary Annual Report for the Plan year ending January 31, 2013.
• Summary Annual Report - Plan Year Ending 1/2013 – This is the Summary Annual Report for the Plan year ending January 31, 2013.
• Summary Annual Report - Plan Year Ending 1/2011 – This is the Summary Annual Report for the Plan year ending January 31, 2011.
• Summary Annual Report - Plan Year Ending 1/2010 – This is the Summary Annual Report for the Plan year ending January 31, 2010.
• Summary Annual Report - Plan Year Ending 1/2009 – This is the Summary Annual Report for the Plan year ending January 31, 2009.
• Summary Annual Report - Plan Year Ending 1/2008 – This is the Summary Annual Report for the Plan year ending January 31, 2008.
• Summary Annual Report - Plan Year Ending 1/2007 – This is the Summary Annual Report for the Plan year ending January 31, 2007.
• Summary Annual Report - Plan Year Ending 1/2006 – This is the Summary Annual Report for the Plan year ending January 31, 2006.
• Summary Annual Report - Plan Year Ending 1/2005 – This is the Summary Annual Report for the Plan year ending January 31, 2005.
• Women's Health and Cancer Rights Act of 1998 – On October 21, 1998, President Clinton signed the Omnibus Appropriations Bill which included a new federal law called the Women's Health and Cancer Rights Act of 1998.
• Summary Plan Description – This is your benefits booklet known as the Summary Plan Description.

Notices

• Coverage for Over-the-Counter (OTC) At-Home COVID-19 Test Kits – Under a new federal mandate, your plan covers OTC at-home COVID-19 tests. Find out which tests are covered, where you can purchase tests at a $0 copay, or how your plan will reimburse you.
• New Evidence of Coverage and Disclosure booklet – This Evidence of Coverage and Disclosure Form booklet describes the terms and conditions of coverage of your Blue Shield health Plan. Please read this Evidence of Coverage and Disclosure Form carefully and completely so that you understand which services are covered health care services, and the limitations and exclusions that apply to your Plan.

SBCs

• SBC - Kaiser Permanente: Traditional Plan – Summary of Benefits and Coverage for the Kaiser Permanente: Traditional Plan.
  (Coverage Period: 8/1/2024-7/31/2025)
• SBC - Blue Shield of California: SFEW Custom HMO – Summary of Benefits and Coverage for the Blue Shield of California: SFEW Custom HMO.
  (Coverage Period: 8/1/2024-7/31/2025)
• SBC - SFEW Health & Welfare Trust: PPO Option – Summary of Benefits and Coverage for the Blue Shield of California: SFEW PPO.
  (Coverage Period: 8/1/2024-7/31/2025)
• SBC - SFEW Health & Welfare Trust: PPO Option – Summary of Benefits and Coverage for the SFEW Health & Welfare Trust: PPO Option.
  (Coverage Period: 8/1/2023-7/31/2024)
• SBC - Blue Shield of California: SFEW Custom HMO – Summary of Benefits and Coverage for the Blue Shield of California: SFEW Custom HMO.
  (Coverage Period: 8/1/2023-7/31/2024)
• SBC - Kaiser Permanente: Traditional Plan – Summary of Benefits and Coverage for the Kaiser Permanente: Traditional Plan.
  (Coverage Period: 8/1/2023-7/31/2024)
• SBC - SFEW Health & Welfare Trust: PPO Option – Summary of Benefits and Coverage for the SFEW Health & Welfare Trust: PPO Option.
  (Coverage Period: 8/1/2022-7/31/2023)
• SBC - Blue Shield of California: SFEW Custom HMO – Summary of Benefits and Coverage for the Blue Shield of California: SFEW Custom HMO.
  (Coverage Period: 8/1/2022-7/31/2023)
• SBC - Kaiser Permanente: Traditional Plan – Summary of Benefits and Coverage for the Kaiser Permanente: Traditional Plan.
  (Coverage Period: 8/1/2022-7/31/2023)
• SBC - SFEW Health & Welfare Trust: PPO Option – Summary of Benefits and Coverage for the SFEW Health & Welfare Trust: PPO Option.
  (Coverage Period: 8/1/2021-7/31/2022)
• SBC - Blue Shield of California: SFEW Custom HMO – Summary of Benefits and Coverage for the Blue Shield of California: SFEW Custom HMO.
  (Coverage Period: 8/1/2021-7/31/2022)
• SBC - Kaiser Permanente: Traditional Plan – Summary of Benefits and Coverage for the Kaiser Permanente: Traditional Plan.
  (Coverage Period: 8/1/2021-7/31/2022
• SBC - Kaiser Permanente: Traditional Plan – Summary of Benefits and Coverage for the Kaiser Permanente: Traditional Plan.
  (Coverage Period: 8/1/2020-7/31/2021)
• SBC - SFEW Health & Welfare Trust: PPO Option – Summary of Benefits and Coverage for the SFEW Health & Welfare Trust: PPO Option.
  (Coverage Period: 8/1/2020-7/31/2021)
• SBC - Blue Shield of California: SFEW Custom HMO – Summary of Benefits and Coverage for the Blue Shield of California: SFEW Custom HMO.
  (Coverage Period: 8/1/2020-7/31/2021)
• SBC - Kaiser Permanente: Traditional Plan – Summary of Benefits and Coverage for the Kaiser Permanente: Traditional Plan.
  (Coverage Period: 8/1/2019-7/31/2020)
• SBC - SFEW Health & Welfare Trust: PPO Option – Summary of Benefits and Coverage for the SFEW Health & Welfare Trust: PPO Option.
  (Coverage Period: 8/1/2019-7/31/2020)
• SBC - Blue Shield of California: SFEW Custom HMO – Summary of Benefits and Coverage for the Blue Shield of California: SFEW Custom HMO.
  (Coverage Period: 8/1/2019-7/31/2020)
• SBC - SFEW Health & Welfare Trust: PPO Option – Summary of Benefits and Coverage for the SFEW Health & Welfare Trust: PPO Option.
  (Coverage Period: 8/1/2018-7/31/2019)
• SBC - Blue Shield of California: SFEW Custom HMO – Summary of Benefits and Coverage for the Blue Shield of California: SFEW Custom HMO.
  (Coverage Period: beginning on or after 8/1/2018)
• SBC - Kaiser Permanente: Traditional Plan – Summary of Benefits and Coverage for the Kaiser Permanente: Traditional Plan.
  (Coverage Period: 08/01/2018-07/31/2019)
• SBC - SFEW Health & Welfare Trust: PPO Option – Summary of Benefits and Coverage for the SFEW Health & Welfare Trust: PPO Option.
  (Coverage Period: 8/1/2017-7/31/2018)
• SBC - Blue Shield of California: SFEW Custom HMO – Summary of Benefits and Coverage for the Blue Shield of California: SFEW Custom HMO.
  (Coverage Period: 8/1/2017-7/31/2018)
• SBC - Kaiser Permanente: Traditional Plan – Summary of Benefits and Coverage for the Kaiser Permanente: Traditional Plan.
  (Coverage Period: 8/1/2017-7/31/2018)
• SBC - SFEW Health & Welfare Trust: PPO Option – Summary of Benefits and Coverage for the SFEW Health & Welfare Trust: PPO Option.
  (Coverage Period: 8/1/2016-7/31/2017)
• SBC - Blue Shield of California: SFEW Custom HMO – Summary of Benefits and Coverage for the Blue Shield of California: SFEW Custom HMO.
  (Coverage Period: 8/1/2016-7/31/2017)
• SBC - Kaiser Permanente: Traditional Plan – Summary of Benefits and Coverage for the Kaiser Permanente: Traditional Plan.
  (Coverage Period: 8/1/2016-7/31/2017)
• SBC - SFEW Health & Welfare Trust: PPO Option – Summary of Benefits and Coverage for the SFEW Health & Welfare Trust: PPO Option.
  (Coverage Period: 8/1/2015-7/31/2016)
• SBC - Blue Shield of California: SFEW Custom HMO – Summary of Benefits and Coverage for the Blue Shield of California: SFEW Custom HMO.
  (Coverage Period: 8/1/2015-7/31/2016)
• SBC - Kaiser Permanente: Traditional Plan – Summary of Benefits and Coverage for the Kaiser Permanente: Traditional Plan.
  (Coverage Period: 8/1/2015-7/31/2016)