FORMS

To request a form, please complete the CONTACT US form below. 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