This notice describes how medical information about you may be used and disclosed and how you can get access to this information. The privacy of your information is important to us. Please review it carefully.
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-2311
Form
Active Employee /
Local Employer /
State Employer
Level 4 self-injectables and specialty medications are available through specific pharmacies for non-Medicare members while members on Medicare have some additional pharmacy options.
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
This is the Model Notice for COBRA Continuation Subsidy under the American Rescue Plan [ARP] Act of 2021. Employers please note that information for qualified beneficiaries must be completed.