Puget Sound Electrical Workers Trusts

Forms

Forms

Change of Address
Dental Claim Form
Enrollment/Beneficiary Form
Enrollment/Beneficiary Form – Associates
Maternity Benefits Application
Medical or Time Loss Claim Form
Prescription – Costco Mail Order Form
Prescription – Elixir – 2023 EX Formulary
Prescription – Elixir Mail Order Form
Prescription – Elixir Reimbursement Form
Vision Claim Form

Privacy and Disclosures

Authorization for Disclosure of Protected Health Information
Health & Welfare Trust – Notice of Privacy Practices
Revocation of Protected Health Information Disclosure
Hospital & Outpatient Surgery Pre-Authorization

You must receive approval for hospitalization or outpatient surgery before admission or no later than 48 hours following an emergency admission. If pre-authorization is not obtained a penalty will be assessed.

For pre-authorization, please call 1-800-783-8606.

Mail completed CLAIM forms to:

PSEW Healthcare Trust
P.O. Box 34970
Seattle, WA 98124-1970

Mail all other completed forms to:

PSEW Trusts
P.O. Box 34203
Seattle, WA 98124-1203