To request a form not listed, please CONTACT US. Please be sure to let us know where you work, as many of the forms are specific to your benefit plan. Your plan-specific form will be emailed to you.
  • Wellness Passport
  • Claim Form
  • Disability Form
  • Life Event Form (marriage, divorce, death, birth, adoption, job loss, loss of insurance coverage)
Click the corresponding buttons below to download Beneficiary-Change Request and HIPAA Authorization forms. To view Heartland Health & Wellness Fund’s notice of privacy practices click here.
Beneficiary Change Request Form
HIPAA Authorization Form
Contact Update Form
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