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.