Healthcare Benefit Trust Fund

HEALTHCARE BENEFIT TRUST FUND ENROLLMENT & AUTHORIZATION

Trust Identification

Trust Name:

Plan / Account Number:    Trust Administrator:

Participant Information

Date of Birth:    Gender:    Social Security (last 4):

Phone:    Email:

Relationship:    Phone:

Employer & Enrollment Details

Hire Date:    Employment Status:

Insurance Information

Policy / ID #:    Group #:

Medical History (Optional)

Current Medications (list names and dosages):

Allergies (medication, food, latex):

Contribution Election & Funding

I elect to contribute to the Healthcare Benefit Trust Fund as indicated below. Contributions will be administered pursuant to the trust document, plan rules, and applicable law.

Contribution Type:    Pre-tax payroll deduction    Post-tax contribution

Effective Date for Deduction:

Beneficiary Designation

Primary Beneficiary Name:

Relationship:    Share (%):

Contingent Beneficiary Name:

Relationship:    Share (%):

Authority, Terms & Certifications

By executing this Enrollment & Authorization, Participant acknowledges and agrees that: the Healthcare Benefit Trust Fund (the Trust) has been established to receive and administer contributions for payment of eligible medical expenses and related benefits as set forth in the trust agreement and plan documents; the Trustee has the authority to interpret plan provisions, determine eligibility and make payments in accordance with controlling plan and trust instruments.

Participant expressly authorizes payroll deductions (if applicable) and irrevocably assigns to the Trustee the right to receive contributions from the employer on Participant's behalf to the extent permitted by plan rules. Participant understands that amounts credited to the Trust are subject to the terms and limitations of the plan document, and that eligibility for any payment is subject to submission of satisfactory documentation of expenses and Trustee's review.

Subrogation & Reimbursement: Participant agrees that the Trust and Trustee are subrogated to any rights Participant may have against third parties for the recovery of benefits paid on Participant's behalf. Participant will cooperate with the Trustee in enforcing those rights and will promptly reimburse the Trust from any recovery, less reasonable costs of recovery, to the extent of Trust payments.

Amendment and Termination: The Trustee or Plan Sponsor reserves the right to amend or terminate the Trust or plan at any time consistent with the plan and trust instruments and applicable law. Pending contributions and claims will be administered pursuant to the terms in effect at the time the claim arose unless otherwise required by law.

Tax Treatment: Participant acknowledges that contributions and benefit payments may have tax consequences. The Trust does not provide tax advice; Participant should consult a tax advisor for guidance.

HIPAA & Privacy Authorization

Participant authorizes physicians, hospitals, insurers, and other healthcare providers and payors to disclose protected health information to the Trustee, Plan Administrator, and their agents as necessary to determine eligibility for benefits, process claims, and administer the Trust. This authorization includes medical records, billing records, and other information relevant to a claim. The information disclosed is to be used solely for plan administration, payment of benefits and related appeals.

Authorization to Disclose: I authorize the disclosure described above.

Expiration of Authorization (optional):   If left blank, this authorization will remain in effect until revoked in writing to the Plan Administrator.

Participant Acknowledgement

I certify under penalty of perjury that the information provided on this form is true, complete, and correct to the best of my knowledge. I understand that any false statement, omission, or misrepresentation may result in denial of benefits and recovery of amounts paid in error, and may subject me to disciplinary action by my employer.

I hereby authorize the Trustee and Plan Administrator to release to and obtain from the employer, insurers, and providers such records and information as may be necessary to administer the Trust, adjudicate claims, and pursue recovery actions. I understand my right to revoke this authorization at any time by submitting written notice to the Plan Administrator, although such revocation will not affect disclosures made prior to receipt of the revocation.

If signing on behalf of Participant, indicate relationship and legal authority to sign (e.g., parent, guardian, power of attorney):

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