Northwest Roofers and Employers Health and Security Trust Fund



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• Claims Forms
  • USAble Life Insurance CLaims
  • Prescription Reimbursement Request Form (Optum)
  • Prescription Mail-In Order Form
  • Optum 2022 Formulary
  • Premium Formulary Exclusions & Preferred Specialty Prior Authorization Requirements
• Medical Forms
  • Enrollment/Beneficiary Form
  • Dental Claim Form
  • Change of Address Form
  • Medical-Time Loss Form
  • VSP Out-Of-Network Reimbursement Form (Only self submitted non-VSP network claims)
• Privacy and Disclosures
  • Authorization for Disclosure of Protected Health Information
  • Health & Security Trust – Notice of Privacy Practices
  • Revocation of Protected Health Information Disclosure