Claim Forms
Medical - This form is used, as requested, by non-network medical providers.
Dental - This form is used, as requested, by non-network dental providers.
Vision - This form is used, as requested, by vision providers.
Flexible Dependent Coverage Claims -
This form is used by participants enrolled in the Program to receive reimbursement from their Medical Spending Account.
BlueCard Worldwide International Claims - This form is used by participants who seek reimbursement for a medical emergency claim where services were rendered outside of the United States.
Mail Service Order Form- This Mail Service Order Form is used by participants to obtain mail order prescription drugs.
Prescription Drug Claims - This form is used by participants who seek reimbursement for a prescription drug claim.
Appeal Form
If your benefit claim is denied in whole or in part, you have the right to appeal. This Notice of Appeal Procedure describes the MCTWF appeal process available to participants and providers.
Participant Benefit Claim Appeal - This form is used by participants to appeal an adverse benefit decision.
Information Change Forms
Change of Beneficiary - This form is used by participants to change the designated beneficiary(ies) listed on their enrollment card.
Family Status Change - This form is used by participants to modify information affecting dependent eligibility.
Contact Updates - This form is used by participants to provide address, telephone number and email address information updates.
Participant Application Forms
Non-Access Exemption - This application is used to apply for in-network treatment coverage from an out-of-network primary care physician, medical specialist or general dentist, outside of the geographic area covered by the BCBS PPO or Delta Dental networks.
Participant's Report of Disability - These forms are required in order to apply for loss of time benefits under the weekly accident & sickness benefit. One copy must be filled out by the participant and the employer and a separate form must be filled out by the physician.
Total & Permanent Disability - These forms are required in order to apply for total and permanent disability benefits. One
two-page copy must be filled out by the claimant, one two-page copy must be filled out by the physician and one two-page copy must be filled out by the employer.
Assignment, Subrogation and Reimbursement Agreement (Work Related) - Execution of this agreement is required to obtain conditional coverage for a work-related illness or injury if the employer and/or the worker's compensation insurance carrier disputes the claim for benefits.
Assignment, Subrogation and Reimbursement Agreement (Non-Work Related) - Execution of this agreement is required to obtain coverage for a non-work related injury or illness caused by a third party.
Flexible Dependent Coverage Program Election Form This form is used by participants who wish to elect MCTWF's Flexible Dependent Coverage Program.
Full-Time Student Eligibility Verification- This form is required each school semester, quarter or other grading period for eligibile full-time students.
Affidavit for Continuing Dependent Full-Time Student Coverage - This form is required to qualify for dependent full-time student coverage for graduate students.
Retiree Plan Application Forms
Retiree Medical Program - This application is used to
apply for MCTWF's Retiree Medical Program.
Retiree Death Benefit Program - This application is used to apply for MCTWF's Retiree Death Benefit Program.