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IUPAT LOCAL 177 HEALTH
AND PENSION TRUST FUNDS
Consent to Release Version 1.0
Electronic Funds Transfer (EFT) Authorization for Claim Payments Version 1.0
Guide to Applying for Freezing of Hours Version 1.0
Guide to Applying for Weekly Disability Benefits Version 2020
Health Spending Account Claim Form Version 1.0
Pre-Determination - Hospital Bed Assessment Form Version 2017
Pre-Determination - Knee Brace Version 2017
Pre-Determination - Nursing Care Assessment Form Version 2017
Pre-Determination - Oxygen Concentrator Assessment Form Version 2017
Pre-Determination - Wheelchair Assessment Form Version 2017
Prescription Drug Special Authorization Request Form Version 1.0
Consent to Release Version 1.0
Electronic Funds Transfer (EFT) Authorization for Claim Payments Version 1.0
Guide to Applying for Freezing of Hours Version 1.0
Guide to Applying for Weekly Disability Benefits Version 2020
Health Spending Account Claim Form Version 1.0
Pre-Determination - Hospital Bed Assessment Form Version 2017
Pre-Determination - Knee Brace Version 2017
Pre-Determination - Nursing Care Assessment Form Version 2017
Pre-Determination - Oxygen Concentrator Assessment Form Version 2017
Pre-Determination - Wheelchair Assessment Form Version 2017
Prescription Drug Special Authorization Request Form Version 1.0
VIDEOS
How do I register for Electronic Health Claim Submissions?
This video will walk you through how to set up your Claim Submission account.
How do I submit a Health Claim electronically?
This video will walk you through how to submit a claim online or in an app.
COMING SOON....
Click the video on the right for detailed information