UFCW & Employers Trust, LLC (UEBT/UCBT) / UFCW-Employers Benefit Plans of Northern California Group Administration LLC fax number

Fax destination details

Department

Health & Welfare Services Department

Purpose

Enrollment documentation submission and release of medical information via the UFCW Health & Welfare Services Department

Form

Authorization for Release of Medical Information — AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

Address

P.O. Box 4100, Walnut Creek, CA 94596-8086

Voice phone

(800) 552-2400

Website

Visit organization website

Before you send

• Confirm that this exact department handles your document or request.
• Check the organization website or call its main line for the current fax number.
• Include a cover sheet and any case, member, claim, or form reference required.
• Keep the delivery confirmation with your submission records.

Complete patient details, select the applicable UFCW fund(s) (UEBT, UCBT, or Northern California Health & Welfare Trust Fund), indicate the UFCW Local staff to receive the information (or authorize any staff member), provide a description of the records to be released, sign and date, and fax to the provided number.

Official form instructions are published as a downloadable file on the organization's website.