General

• HCFA-1500 Form - use this form to submit non-California Blue Card claims, accompanied by an itemized bill with the diagnoses and procedure codes.
• Authorization to Release Information - Complete this form if you would like to authorize a person or entity to receive Health and Welfare information on your behalf.
• Address Change Packet - It is very important that the Administrative Office has the Participant’s/Beneficiary’s updated address for Plan correspondence. If the Participant/Beneficiary recently moved, please complete all necessary components of this Address Change Packet and return it to the Administrative Office.
• Designation of Beneficiary for Life Insurance - Use this form to designate a beneficiary for life insurance.
• Dependent Enrollment form - Use this form to add dependents to your insurance policy.
• W-9 Form - This link provides the IRS form that must be completed by all new providers being added to the Fund's provider file. If claims have been denied for the W9 form, this form can be printed and given to your provider for submission to the Fund office. This form is required by the IRS before benefits can be released to a provider of service.
• Coordination of Benefits - This form is needed to update the Fund office with your Coordination of Benefits information. You should provide the Fund office with an updated form annually.
• Prescription Drug Reimbursement Form - This form is needed to submit claims for reimbursement for medication purchased.
• Coordination of Benefits/Direct Claim Form - This form is needed to submit prescription drug claims under the Coordination of Benefits Rule.
• Summary of Material Modifications for CBS Retirees (January, 2009) - The Writers’ Guild-Industry Health Fund released an updated version of the Summary Plan Description for CBS Retirees in January 2009. This communication will detail some clarifications to the SPD identified over the past few months.
• Medco Mail Order Form - This form is used for the Mail Order Pharmacy Benefit. Please complete the form and attach scripts obtained from your doctor for all "maintenance drugs" you and/or your covered dependents use.
• Lien and Reimbursement Agreement - Have you been involved in an accident? Did you slip and fall while you were on someone else's property? Did someone else cause an injury to you? If so, this "Third Party Liability" coverage may be responsible for providing reimbursement for your medical care. The Fund office will deny all accident related charges until the form is completed, signed and returned.
• Disability Application - This is one of two forms needed to apply for a disability extension of coverage under the Fund. Please complete your portion of this form and return it to the Fund Office with a completed Attending Physicians Statement.
• Attending Physicians Statement - This form is one of two needed to apply for a disability extension of coverage under the Fund. Please have your doctor complete this form and return it to the Fund Office with a completed Disability Application.
• Dental Claim Form - Use this form to submit a claim to Delta Dental.
• Student Certification - This form has been removed from our website as it is no longer required by the Health Fund to extend coverage for dependents between the ages of 18 and 26. If you need to submit certification for a college quarter/semester prior to January 1, 2011, please contact the Eligibility Department to request a form.

Health Information Privacy

• Privacy Notice - In compliance with the HIPAA regulation, the Fund office has developed a Privacy Notice advising our Participants of their rights under this regulation.

Official Plan Documents

• Summary Annual Report For Health Fund - This report is sent annually to all participants. It summarizes the findings of the annual independent audit required for all health plans
• Health Fund Trust Agreement - The Trust Agreement is the document which constitutes and governs the operations of the Health Fund. The Agreement is between the WGA and the Producers and is in accordance with the Collective Bargaining Agreements between the parties.
• Amendment I to the Health Fund Trust Agreement -
• Amendment II to the Health Fund Trust Agreement -
• Amendment III to the Health Fund Trust Agreement -
• Amendment IV to the Health Fund Trust Agreement -
• Amendment V to the Health Fund Trust Agreement -
• Amendment VI to the Health Fund Trust Agreement -
• Amendment VII to the Health Fund Trust Agreement -
• Amendment VIII to the Health Fund Trust Agreement -
• Summary of Material Modifications (2004) - The Writers’ Guild-Industry Health Fund released an updated version of the Summary Plan Description in early May 2004. This communication will detail some clarifications to the SPD identified over the past few months.
• Summary of Material Modifications (2005) - The Writers’ Guild-Industry Health Fund released an updated version of the Summary Plan Description in September 2005. This communication will detail some clarifications to the SPD identified over the past few months.
• Summary of Material Modifications to the Health Plan (July, 2009) - The Writers’ Guild-Industry Health Fund released an updated version of the Summary Plan Description for the Health and Welfare Plan in July 2009. This communication will detail some clarifications to the SPD identified over the past few months.
• Summary of Material Modifications for CBS Retirees (May, 2010) - The Writers’ Guild-Industry Health Fund released an updated version of the Summary Plan Description for the Health and Welfare Plan in May 2010. This communication will detail some clarifications to the SPD identified over the past few months.