Forms

Download your forms

This page provides you with easy access to all of the MCTWF’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.

Medical

This form is used for reimbursement for allowed costs for non-network medical services.

Dental

This form is used for reimbursement for allowed costs for non-network dental services.

Vision

This form is used for reimbursement for allowed costs for non-network vision services.

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.

At-Home COVID-19 Test Reimbursement Claim Form

This form is used by participants who seek reimbursement for over-the-counter at-home COVID-19 tests purchased.

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 an accidental death or dismemberment benefit.

COVID-19 Weekly Accident & Sickness Benefits Claim Form

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.

Extended Disability – Claimant’s Report of Disability

This form is used by individuals that are applying for the Extended Disability benefit.

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 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.

Death Benefit Claim Form

This form is used by beneficiaries who seek payment of a death benefit.

Flexible Dependent Coverage Claims

This form is used by participants enrolled in the Program to receive reimbursement from their Medical Spending Account.

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.

Check Replacement Form Affadavit

This form is used to report a lost or stolen check.

BCBSM Member Application for Payment Consideration

This application is used by participants for reimbursement of special formulas and medical foods.

Notice of Appeal Procedure

If your benefit claim is denied in whole or in part, you have the right to appeal. This Notice of Appeal Procedure 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.

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

Enrollment Card

This form is used by new participants to provide MCTWF with the demographic, beneficiary, and other insurance 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.

Contact Updates

This form is used by participants to provide address, telephone number and email address information updates.

Coordination of Benefits Information

This form is used by participants to modify information affecting dependent coordination of benefits.

Family Status Change

This form is used by participants to modify information affecting dependent eligibility.

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.

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.

Request for Continuation of Coverage Beyond Age 26 for Totally & Permanently Disabled Dependent

This form is used by adult children of a participant, age 26 or greater, who are totally and permanently disabled and need their coverage continued beyond age 26.

Flexible Dependent Coverage Program Election Form

This form is used by participants who wish to enroll in the Flexible Dependent Coverage benefit which provides a health reimbursement account to cover certain medical, dental, and vision expenses for your and your eligible dependents that are not reimbursed by MCTWF or other group health plans.

MCTWF Retirees Plan Enrollment Application

This application is used to apply for MCTWF’s Retiree Medical Program.

MCTWF Retirees Plan ONLY – Authorization for Monthly Electronic Funds Withdrawal

Once you have been approved for enrollment in the Retiree Medical Plan, you have the opportunity to have electronic payments made directly to MCTWF from your bank account (Electronic Funds Transfer – EFT) to cover your monthly contribution requirement by completing the form below. Note: The availability of this service is limited to the Retiree Medical Plan. It is not available for any other self-contribution requirements for any other MCTWF benefit.

Retiree Death Benefit

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

HIPAA Privacy Forms

The full list of all MCTWF forms pertaining to The Health Insurance Portability and Accountability Act of 1996 (HIPAA), and the HIPAA Privacy Rule, can be found here.