Forms
1.

Change of Address Form
It is necessary for the DGA-Producer Pension and Health Plan to have the most current address for each participant. Therefore, please file the attached Change of Address form with the Plans' office whenever you move.
2.

Dependent Enrollment Form
This form must be submitted to the Health Plan when enrolling new dependents under your health coverage.
3.
 Dental Plan Claims Form
When you visit a non-Delta Dental dentist, this form must be filled out and be accompanied by an itemized bill. If you visit a Delta Dental dentist, the dentist will take care of the necessary paperwork.
4.
 Health Plan Claims Form
When you visit a non-PPO (out of network) provider, this form must be filled out and be accompanied by an itemized bill with diagnoses and payment sheets. If you visit a PPO (in-network) provider, the doctor will take care of the necessary paperwork.
5.

Health Plan SPD
This is the July 1, 2003 Health Plan Booklet that describes the benefits offered through the DGA-Producer Health Plan.
6.

Health Plan SPD Updates
This details changes made to the DGA-Producer Health Plan since the
publication of the July 1, 2003 Health Plan SPD.
7.

HIPAA Authorization Form
This form authorizes the DGA-Producer Health Plan to release protected health information on your behalf or on behalf of your dependents to a third party. Please note that you must submit a separate form on behalf of each family member over the age of 18 (signed by that family member) if you wish the Plan to release protected health information to a third party on their behalf. Please note that this form does not allow the Plan to release non-health information.
8.

Prescription Drug Claims Form
When you obtain prescription drugs from a non-Medco pharmacy, you will have to pay the full amount of the purchase to the pharmacy and then fill out this claim form and submit it to Medco for partial reimbursement. If you visit an Medco pharmacy, there is no paperwork.
9.
 Vison Service Plan Out of Network Reimbursement Form
When you visit a non-VSP vision provider, this form must be filled out and accompanied by an itemized bill. If you visit a VSP provider, the provider will take care of all of the necessary paperwork.
Pension Plan Forms:
1.
 Authorization to Release Information to a 3rd Party (non-HIPAA)
This form authorizes the DGA-Producer Pension and Health Plans to release non-health related information to a third party (e.g. pension information, contribution information, etc.). Please note that this form does not allow the Plan to release protected health information.
2.

Basic Plan Direct Deposit Form
If you are receiving a monthly pension benefit from the DGA-Producer Basic Pension Plan, this form allows you to have the benefit amount deposited directly into a bank account.
3.

Basic Plan Withholding Form
If you are receiving a monthly pension benefit from the DGA-Producer Basic Pension Plan, this form allows you to elect the amount of Federal and State taxes that will be withheld from your monthly pension benefit.
4.

Beneficiary Designation Form
This form allows you to designate a beneficiary or beneficiaries to receive your Basic and Supplemental Pension Plan benefits, in the event of your death.
5.

Change of Address Form
It is necessary for the DGA-Producer Pension and Health Plan to have the most current address for each participant. Therefore, please file the attached Change of Address form with the Plans' office whenever you move.
6.

Pension Plans SPD
This is the January 1, 2001 Pension Plans Booklet that describes the benefits offered through the DGA-Producer Pension Plans.
7.

Pension Plans SPD Updates
This details changes made to the DGA-Producer Pension Plans since the publication of the January 1, 2001 Pension Plans SPD.
8.

Retirement Application Request Form
This is the form requesting a retirement application package from the DGA-Producer Pension Plans. This is not the retirement application.
Employer Contribution Forms:
The following forms are for signatory production companies making contributions to the Directors Guild of America - Producer Pension and Health Plans. The forms are available in both Microsoft Excel format and Adobe Acrobat format. The appropriate form is based on the project under which the project being reported is being produced. You may report multiple projects from the same agreement on the same form.

If you are unsure as to the proper form with which to submit contributions to the Plans, please contact the Plans at (323) 866-2200, Option 2 or toll-free outside the Los Angeles area at (877) 866-2200, Option 2.
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PAC
Several of these forms require Adobe Acrobat Reader. If you don't have Acrobat Reader you can download it here for free.