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By signing this form, I authorize  (1) the Fund to share my eligibility and enrollment information with my Employer, the Union, BeneStream, or Healthfirst; (2) Any healthcare provider to release to the Fund and its agents any records or information concerning me or any member of my family receiving benefits from the Fund; (3) BeneStream and/or Healthfirst to contact me to conduct additional benefit screening and/or enrollment assistance; (4) Healthfirst to contact me using automated means, including email, phone, or text, about Healthfirst products, services, and health-related information. Message and data rates may apply. Submitting this form does not obligate me to enroll in a Healthfirst plan.

This form is being used to determine how the 1199SEIU National Benefit Fund for Home Care Employees (1199SEIU Home Care Benefit Fund) provides you with health coverage. If you have any questions, or wish to complete this process by phone, you can call our partners at BeneStream toll-free Monday to Friday, 8am - 8pm, at (833)-521-1981.