Forms

Call Member Services at Wabash Memorial Hospital Association (217) 429-5246 or toll free at (888) 800-9161  if you need assistance in completing any of the forms listed below. 

APPLICATIONS FOR MEMBERSHIP

Railroad Employees:

Active Contract Employees - Primary Coverage

Early Retirees Not on Medicare - Primary Coverage

Former Railroad Employees Not Retired

Active and Former Employees - Secondary Coverage

Medicare Supplemental Coverage

Relatives of Current and Former Railroad Employees:

Primary or Secondary Coverage

Medicare Supplemental Coverage

OTHER FORMS

Automatic Withdrawal Authorization Form (ACH) Allows Wabash to withdraw your dues payment automatically from your bank account. 

Authorization For Release of P H I 2013  Allows Wabash to share your claims, payment and/or medical information with family members and others. 

You need Adobe Acrobat Reader installed on your computer to open and download any of the forms.  It is a free download and you may download it by following this link.