ET-2385
Form Active Employee / Local Employer / State Employer

Health Savings Account (HSA) Enrollment

For UWs use only, as a paper alternative for a member who cannot complete their HSA enrollment online.

Flyer Active Employee / Retiree / Other Benefit Recipient / Board Member / Local Employer / State Employer

Hill Farms 1st Meeting Rooms-Map Only

A map of the first floor of the Hill Farms building labeled with room numbers and an arrow to the main entrance lobby.

ET-7414
Form Active Employee / Retiree / Other Benefit Recipient

Authorization to Disclose Medical Information

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-4307
Form Active Employee / Retiree

Medicare Eligibility Statement

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.