Date: May 21, 2021
RE: Address Change Form and Authorization Form
Dear Health & Welfare Fund Participant,
We are forwarding the address change form that you requested. As, you know, the AFSCME District Council 47 Health & Welfare Fund ("Fund") is closely affiliated with information on file, the Fund will, subject to your authorization, provide the information listed on this form to the Union. The Fund is required by the Health Insurance Portability and Accountability Act of 1996 ("HIPPA") to protect your "protected health information", including the information on this form. You will assist the Fund and the Union by authorizing the Fund to share the information on the enclosed form (and only the information on the enclosed form) with the Union in order to make sure that all your file information is up to date. The information provided to the Union will be limited to the information below.
By signing and submitting this form, you are authorizing the Fund to disclose the information below to AFSCME District Council 47. This authorization is voluntary. You may revoke it at any time by informing the Fund in writing. This authorization is effective for ninety (90) days from the date of this letter, unless revoked or terminated by you or your personal representative. You should note that the Union is very careful in its handling of your personal information. However, it is possible that the information may be disclosed again by the union.
You can fill the form out below OR print out and fax the form to 215-545-7052 or mail it to the Fund Office at: 1606 Walnut Street, Philadelphia, PA 19103.
Printable form: CLICK HERE