Employee Benefit Funds Administration Ltd

Employee Benefit Funds Administration Ltd.

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Page updated: March 29, 2022
 

EBFA Forms
  Note: Please make sure that you are eligible for Health and Welfare benefits before incurring any medical expenses or submitting claims to the Fund Office.
 
  EBFA Forms Adobe Acrobat(.pdf)
 Dental - Direct Reimbursement Form Click Here
 Disability Notice Click Here
 Supplementary Health Expense Form Click Here
 Supplementary Health Expense Form - Supplies Click Here
 Supplementary Health Expense Form - Orthopedic Boots  Click Here
 Supplementary Health Expense Form - Orthotics Inserts  Click Here
 Supplementary Health Expense Form - Private Duty Nursing Click Here
 Supplementary Health Expense Form - CPAP Machine and Supplies Click Here
 Prescription Drug - Direct Reimbursement Form Click Here
 Prescription Drug - Applying for Special Authorization Drug Click Here
 Prescription Drug - Maximum Purchase Exception Click Here
 Physician's Medical Referral Click Here
 Vision - Direct Reimbursement Form Click Here
 Dependent Update Form Click Here
 Self-Pay Pre-Authorized Debit (PAD) Plan Agreement Click Here
 Self-Pay Bank Change Form Click Here
 Self-Pay Cancellation Notice of Pre-Authorized Debit (PAD) Plan Agreement Click Here
 Registration and Declaration of Beneficiary Form Click Here
 Form 5 Click Here
 Form 9 Click Here


Download Adobe Acrobat Reader Here
Terms and Conditions of Use

Terms

All information on this website, any internal links, external links, redirections to this website, hyperlinks or the like (collectively this "Website") have been provided in order to provide direct access to information regarding certain programs, qualifications, services and the like offered by the Employee Benefit Funds Administration Ltd. of any related entity or subsidiary thereto (collectively referred to as "EBFA"). The information herein has been posted with the intent that it be readily available and accessible for personal use of members or other interested parties.

Reproduction

Any and all materials and information on this Website, inclusive of the underlying HTML, text, illustrations, designs, icons, any audio or video clips or attachments, products, software and any and all other content contained herein (collectively referred to as the "Material") is either owned by EBFA or EBFA has obtained the right, license or other permission to use or display same. Unless the Material is for personal use of members or other interested parties or for an approved purpose otherwise stated herein, none of the Material, or any portion thereof, may be copied, reproduced, distributed, republished, downloaded, displayed, posted, transmitted or in any way used unless prior written consent is obtained from EBFA. The use of the Material or this Website for any commercial purpose or commercial distribution is specifically prohibited.

Disclaimer

EBFA makes every effort to ensure that this Website contains accurate, correct and up-to-date information. In doing so, EBFA goes to great lengths to ensure the accuracy of the information and Material posted. Notwithstanding this, it must be noted that there may be instances where the information is not current and/or may have changed since this Website was last updated. The information and Material on this Website is provided on an "as is" basis without any warranties or conditions, either expressed or implied, relating to the accuracy of the information or Material. To the fullest extent possible under law, EBFA specifically disclaims all warranties and conditions, expressed or implied, including but not limited to implied warranties or conditions of merchantability and fitness for a particular purpose or any representations regarding the use, accuracy, timeliness, applicability, performance, security, availability or reliability of the Website. It is hereby recommended that you not rely or undertake a specific course of action based on the information or Material contained in this Website without consulting our offices further.

Limitation of Liability

Notwithstanding any provision of these Terms and Conditions of Use, under no circumstances, including but not limited to negligence, shall EFBA be liable for any direct, indirect, special, punitive, incidental or consequential damages arising out of, or in any way connected to, the use, misuse, inability to use or information or Materials contained in this Website.

Links to other website(s) and Links from other website(s)

Hyperlinks or pathways to websites not under the specific control of EBFA, but provided on this Website are provided solely for the convenience of users and EBFA is not liable, responsible or necessarily endorses the content contained in such other websites.

There may be circumstances where access to this Website is provided by a hyperlink or pathway located on another website. In such instances, EBFA is not liable, responsible or necessarily endorses the content contained in such other websites.

Right of Access and Termination

EBFA may withhold, terminate, limit, or otherwise control any user's access to this Website, or any portion thereof, at any time if EBFA determines, in its sole discretion, that such user failed to comply with any terms contained in the Terms and Conditions of Use contained herein or otherwise offends the intent of the Terms and Conditions of Use. In addition, if EBFA, in their sole discretion, believes that any user is posing a threat, harm, danger or nuisance to this Website or any other users through their use of this Website, EBFA may withhold, terminate, limit or otherwise control any such user's access to the Website.

Should EBFA, in their sole discretion, terminate the right of access of any user to this Website, the user must cease any and all use of the Website, return or destroy any and all information or Material obtained from this Website to EBFA and/or conform to and abide by any reasonable direction or instruction from EBFA regarding such information or Material.

Copyright © 2004-2016 Employee Benefit Funds Administration Ltd.