You can open the following forms in your web browser and print them to your own printer. The forms are in Adobe PDF Format. You will need the Adobe Acrobat Reader program to view or print any of the forms. This is a free program available from the Adobe website. If you do not have Acrobat Reader click on the link and install the software before you click on the links to view the forms.
After printing the necessary form(s), you can return the completed and signed form(s) to the Plan Administrative Office via fax at (925) 426-3565 or by mailing them to the following address:
Employers Managed Health Care Trust
P.O. Box 757
Pleasanton, CA 94566
If you do not have access to a printer, you can contact the Plan Administrative Office at (800) 924-1226 to request that a form be mailed to you.
Please note that if you are in the process of enrolling a new dependent under your health and welfare plan, and the dependent has a different last name than your own, you will need to provide proof of the dependent’s eligibility through submission of a copy of the appropriate, certified documents (i.e., a marriage certificate for a spouse/birth certificate for a child).
Trust Fund Forms
Retiree Provider Forms
Additional Helpful Documents from Providers