Contacts

 

 

 

 

 

This page provides you with easy access to all of theMCTWF's forms, along with a brief description of their use. Use these forms to print, fill out and mail to the MCTWF office at the address listed on the contacts page (note that these forms cannot be filled out and submitted electronically).  Adobe Acrobat Reader is required for viewing and printing and can be downloaded free of charge by clicking on the Acrobat Reader icon on this page.



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 non-network vision providers.

Prescription Drug Claims - This form is used by participants who seek  reimbursement for a prescription drug claim.

Mail Service Order Form- This Mail Service Order Form is used by participants to obtain mail order prescription drugs.

Flexible Dependent Coverage Claims - This form is used by participants enrolled in the Program to receive reimbursement from their Medical Spending Account.

Death Benefit Claim Form- This form is used by beneficiaries who seek payment of a death benefit.

Total Disability Certification Form- This form, which must be provided annually to remain eligible, is used by those whose Total Disability Death Benefit has been reinstated.

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.   


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.


Participant/Family Information Forms

Enrollment Card - This form is used by new participants to provide MCTWF with the demographic, beneficiary and other insurance information information necessary to enroll in the plan. When fillling out the form refer to the Required Beneficiary Documents to determine if additional information is needed.

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 short-term disability benefits. 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.

Adult Child Coverage Application for Enrollment Due to the Loss of Eligibility to Enroll in a Non-Parental Health Plan This form is used by adult children (those age19-26) who are no longer eligible to enroll in an employer sponsored non-parental health plan.

BCBSM Member Application for Payment Consideration- This application is used by participants for reimbursement of special formulas and medical foods.


Retirees Plan Application Forms

MCTWF Retirees Plan Enrollment Application - This application is used to apply for MCTWF's Retiree Medical Program.

Retiree Death Benefit - This application is used to apply for MCTWF's Retiree Death Benefit. 


HIPAA Privacy Forms

For a description of each of the forms listed below, please refer to the Notice of Privacy Practices located on the HIPAA Privacy Rule page of this website.

Individual Authorization to Release PHI

Individual Request for Access to PHI

Individual Request for Confidential Communications of PHI

Individual Request for Accounting of Disclosures of PHI

Revocation of Authorization to Release PHI

Individual Request to Amend PHI

Individual Request for Restrictions on Use/Disclosure of PHI
   
 

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