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

   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 - 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 of Enrollment in Graduate School -   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.