Forms : AGC – International Union of Operating Engineers Local 701 Trust Funds

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Claim Forms
Enrollment and Changes
- Change of Address Form
- Enrollment/Beneficiary
Discloure and Privacy

Preauthorization

You must receive approval for hospitalization or chemical dependency treatment before admission or no later than 48 hours following an emergency admission. For pre-authorization, please call 800-827-5058.

Where to send completed forms

Active and Non-Medicare Retirees

Medical and Vision Claims

PPO Services Obtained in Oregon mail claims to:
Regence BlueCross BlueShield of Oregon
PO Box 30805
Salt Lake City, UT 84130-0805
PPO Services Obtained in Washington & Alaska mail claims to:
Premera Blue Cross
PO Box 91080
Seattle, WA 98111-9180
All Other Areas mail claims to:
Local BlueCard Plan

Member Paid Claims, Dental Claims, and Time Loss Claims mail to:

AGC IUOE Local 701 H&W
PO Box 34687
Seattle, WA 98124-1687

Medicare Retirees

Mail ALL claims to:
AGC IUOE Local 701 H&W
PO Box 34687
Seattle, WA 98124-1687

All Other Completed Forms:
Administration Office
15 82nd Drive, Suite 110
Gladstone, OR 97027

AGC - International Union of Operating Engineers Local 701 Trust Funds

Health & Welfare

Forms