Employers and Operating Engineers Local 520
Health & Welfare, Pension, Annuity & Vacation
Eight Executive Woods Court
Swansea, IL 62226-2057
Phone: (618)-233-7978 Fax: (618)-233-7716
The Employers and Operating Engineers Local 520 Health and Welfare Fund providers for an outpatient physical exam once every coverage period (June 1 through May 31) for participants, their spouses and adult dependent children only. Attention Medicare Participants: If Medicare is your primary carrier, the fees incurred for the physical exam must be submitted to Medicare first. Attention Cigna Participants: Fees incurred for the physical exam should be submitted to: Cigna Payor 62308 PO Box 188004 Chattanooga, TN 37422-8004
Please indicate the examinations, x-rays and lab test performed including the date and the facility. (To qualify for the Physical exam benefit, at least one of the diagnostic services listed below must be done along with an office visit.)
Labs
OPTIONAL
I wish to have the Health and Welfare Fund pay the Physician/Facility directly. (Assignment)
PLEASE RETURN THIS COMPLETED CLAIM FORM TO THE FUND OFFICE
*****Questions: Contact the Benefit Fund Office*****