National Medical Support Notice

Program Option
  • 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
Health and Wellness News
Nov 19, 2024 1:00pm
Child holding a vegetable and placing it near their parent's ear. Graphic texts: WHERE YOU BELONG: Find health and closer connection. It's Your Health: Diabetes

November is National Diabetes Month

Join us this month in learning about diabetes, prediabetes, and Well Wisconsin's diabetes management coaching program.

Notice of Privacy Practices

Program Option
  • 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
ET-6301
Form Other Benefit Recipient

Notice of Death

Notify the third party administrator of the group life insurance program of a member death.

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.

Notice of Creditable Coverage for Medicare Part D

Program Option
  • 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
ET-7406
Form Active Employee / Retiree / Other Benefit Recipient

Authorization to Disclose Non-Medical Information

Wisconsin law allows ETF to release personal information to a third party if the member has first provided ETF with a valid written authorization. Use this form to authorize the release of non-medical information.

Video
3 minutes
Woman talking to doctor in office

Get Medical Care When You Need it Fast

Have you ever needed medical care and didn’t know where to turn? In this video you'll learn about your care options and the advantages of each, including which is easiest on the wallet.

Equal Employment Opportunity Commission (EEOC) Notice Regarding Wellness Program

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