Forms

Complete & Print Forms – You can complete most of the forms listed below right on your computer before you print. Simply click on a field in the form and type in the appropriate information. Then print the completed form, sign and mail it to the Trust Office.

These printable forms are in PDF format. To read and print them, you need the free Adobe Acrobat Reader (which is probably already installed in your system). Click here if you do not have Adobe Reader installed on your system.

General/Privacy

  • Address Change Form — Form for address changes.
  • Glossary of Health Coverage and Medical Terms  — This glossary defines many commonly used terms, but isn’t a full list.
  • Privacy Notice — This is the official Privacy Notice of the Plan as required by the HIPAA regulations.
  • Release of Health Information — The Health Insurance Portability and Accountability Act of 1996 (HIPAA) protects the health information of each patient. The Alaska Teamster Welfare Trust (the “Plan”) is prohibited from releasing protected health information except in very specific circumstances. You have the right to request that the Plan release your protected health information to another party (such as another family member); however, you must provide such permission in writing.

Enrollment/Eligibility

Brochures

  • Elixir Pharmacy — Mail order service is required for those patients who require medications on a recurring basis. The medications will be mailed directly to your home.
  • AmWINSRx Formulary (Preferred Drug) List — A guide to preferred drugs within select therapeutic categories for plan participants and health care providers.
  • AmWINSRx Member Reimbursement Form — Submit the reimbursement form to AmWINSRx along with prescription labels to receive reimbursement for medications purchased at out of network pharmacies.
  • RelianceRx Specialty Medication List — Specialty Medications are generally utilized for treating unique disease conditions and are typically injectable or that otherwise require special handling considerations.
  • Using Your Vision Service Plan Benefit (VSP Flyer) — Vision Service Plan benefits at a glance, information on using your Vision Service Plan benefits, and more. To request reimbursement for out-of-network vision services, please complete the VSP Member Reimbursement Form and submit the reimbursement form to VSP along with a legible copy of your itemized receipt.
  • HealthCare Strategies – Important Plan Information for all Eligibile Participants — As part of Alaska Teamster Employer – Welfare Trust continued efforts to provide employees with a robust, affordable health benefit plan, we have partnered with HealthCare Strategies, Inc. (HCS) to help us in our mission. Please read the enclosed information for important details regarding this program.

HRA for AILU Only

  • HRA Claim Form — Claims form for HRA participants.
  • Direct Deposit — Authorization for reimbursements from your Health Reimbursement Arrangement directly to your bank account.
  • How to Guide — HRA mobile application instructions and online how to guide. The mobile application and secure online portal gives you 24/7 access to view information and manage your Flexible Spending Accounts.

Retirees

Legally Required