Documents/Forms

Documents

Legal Notices
Your Rights and Protections Against Surprise Medical Bills (12/20/2022)
Transparency in Coverage Rule – Machine Readable File [use EIN 316041107] (7/1/2022)

Forms

Forms
HIPAA Authorization Form
2024 Health Screening Form
Heartland Health and Wellness Fund
  • 7250 Poe Avenue, Suite 300 Dayton, OH 45414
  • Office Hours: Monday — Friday 8 a.m. — 5 p.m. EST
  • Phone: 937.665.1900
  • Fax: 937.665.0900
  • Email: admin@ufcwbenefitplan.com
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