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.