The Central States Joint Board Health & Welfare Trust Fund (“Health & Welfare Fund”) provides welfare benefits to you and your Dependent(s) through collective bargaining. In order to keep health care cost at the lowest rate possible for you and your Dependent(s), in certain circumstances, the Health & Welfare Fund will request additional information regarding the medical services received in order to determine if another plan or party could be responsible for the cost of your medical services.
If the Health & Welfare Fund is unable to obtain the additional requested information, your claim will be denied. Accordingly, in order for the Health & Welfare Fund to receive the additional requested information as soon as possible, please complete and submit the Questionnaire that can be found at link below. Once you complete and submit the below Questionnaire, the Health & Welfare Fund will receive your response through this website.
If any further information is required, the Health & Welfare Fund’s Subro Response Unit will contact you.
If you have any questions regarding this Questionnaire, please contact the Subro Response Unit at (312) 757-5463 or via email at firstname.lastname@example.org.
HIPAA PRIVACY NOTICE: Please be advised that it is the intention of the Health & Welfare Fund to implement technical security measures to guard against unauthorized access to electronic protected health information that is being transmitted over an electronic communications network in compliance with 45 CFR Part 164, Subpart C. Although the Questionnaire is submitted through a secured server, the information contained in the Questionnaire is not encrypted and therefore may be susceptible to risk of unauthorized disclosure. By submitting the Questionnaire, you assume the risk and the Health & Welfare Fund is not responsible for unauthorized access of protected health information contained in the Questionnaire while in transmission. Alternatively, you have the right to submit this Questionnaire via facsimile at (312) 757-5463.