ETF complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity.
This form gives ETF and entities that perform contracted services for ETF permission to release your designated medical information to a person or entity specified by you.
ET-9019
Active Employee /
Retiree /
Local Employer /
State Employer
LAHP is a program that provides group health insurance for retirees whose group health insurance with their former employer does not meet their needs or is not permanently available after retirement.
The Well Wisconsin program, administered by WebMD, provides tools and resources to help participants set health and well-being goals, track progress, stay motivated, and earn incentives.
Program Option
Local Annuitant Health Program (LAHP)
Local Deductible Health Plan (PO14) & Supplemental Benefits
Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits
Local Health Plan (PO16) & Supplemental Benefits
Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits
Local High Deductible Health Plan (PO17) & Supplemental Benefits
Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits
Local Traditional Health Plan (PO12) & Supplemental Benefits
Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits
State Employee and Retiree Health Plan & Supplemental Benefits
The group health insurance program is an employer-sponsored program offering group health coverage to employees of state agencies, UW System, UW Hospital & Clinics Authority and participating local government employers.
You and/or your insured dependents must be enrolled for both portions of Medicare (Hospital Part A and Medical Part B), when first eligible. Provide this information to ETF using this form.
