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Plan Information, Forms, and Brochures . . .

It is important for employers participating in any one or more of the Health Trust plans to understand the Health Trust’s guidelines for eligibility and enrollment. The Health Trust provides each participating employer group with a copy of the Health Trust’s Reference Guide to Billing and Enrollment. This Guide is updated on a regular basis.

The following forms are interactive PDF forms. Type the information into them, PRINT, and mail in with signatures. The information can not be saved.

Billing Information and Enrollment Forms:

Billing Schedule

Medical Enrollment/Change Form
Dental Enrollment/Change Form
Income Protection Plan Enrollment Form
Vision Enrollment/Change Form
Life Enrollment Form
Life Plan Change Form
Domestic Partner Affidavit

Change Forms:

Salary Change Form
Termination Notification Form [PDF] or [Word]
Retiree Eligibility Form [PDF] or [Word]
Change of Address Form [PDF]

Please use the links to the left to access informational brochures on the Health Trust’s plan offerings, including: Medical plans, Life insurance plans, Disability Plans, Dental plan, Vision plan and Retiree medical plan.






Brochures & Forms
B & E Guide
Billing Schedule
HIPAA Privacy Notice
HIPAA Authorization
HT Claim Forms
Employee Benefits
Retiree Benefits
Wellness Works
Contact Us

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