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.
Accidental Death and Dismemberment Claim Form- This form is used by a participant for accidental dismemberment or by beneficiaries for accidental death who seek payment of a accidental death or dismemberment 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.
Blue Cross Blue Shield Global Core International Claim Form- This form is used by participants who seek reimbursement for a medical emergency claim where services were rendered outside of the United States.
If your benefit claim is denied in whole or in part, you have the right to appeal. This Notice of Appeal Procedure for Grandfathered benefit packages describes the MCTWF appeal process available to participants and providers.
If your benefit claim is denied in whole or in part, you have the right to appeal. This Notice of Appeal Procedure for Non-Grandfathered benefit packages 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.
Provider Authorization Forms
These forms must be filled out by your provider and sent to MCTWF's Utilization Review Department for the appropriate service or medical equipment that requires prior authorization for -
Prior Authorization of Surgery Services
Prior Authorization of Radiology Services
(Echocardiogram, MRI, MRA, CT Scan and Pet Scan)
Prior Authorization of In-Lab Sleep Study Services
Prior Authorization of Speech Therapy Services
Prior Authorization of Durable Medical Equipment Purchases
Prior Authorization of Colonoscopy Services
Prior Authorization of Home Health Care/Hospice
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 filling 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.
Total & Permanent Disability Request for Continuation of Coverage Beyond Age 26 for Totally & Permanently Disabiled Dependent - These forms are required in order to apply for continuation of coverage of dependents who are beyond age 26 and are totally and permanently disabled. One two-page copy must be filled out by the participant and signed by the participant and the disabled dependent.
Claimant's Report of Disability - MCTWF Extended Disability-This form is used by individuals that are applying for the Extended Disability benefit and were not on short term disability prior to the commencement of the extended disability.
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.
Adult Child Coverage Application for Enrollment
This form is used by adult children (those age19-26) who have missed their opportunity to enroll in their participant/parent's MCTWF health plan.
Flexible Dependent Coverage Program Election Form This form is used by participants who wish to elect MCTWF's Flexible Dependent Coverage Program.
BCBSM Member Application for Payment Consideration- This application is used by
participants for reimbursement of special formulas and medical foods.
Continuity of Care Application- This application is used by Local 554 participants and their eligible family members to continue receiving in-network benefit levels for services related to certain medical conditions rendered by CHI and UniNet providers for a limited period of time.
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.
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