We have all claim forms available for download in PDF format. If you do not have Adobe Acrobat Reader, you can download it here.
Complete this form for medical claims that are pending for accident information. Members can use this form if they have lost the Accident Questionnaire that was mailed to them on a claim. Click here for link
ACH transfer service for Retirees who are enrolled in retiree self pay. Click here for link
Complete this form only if your dependent has lost his/her own medical health insurance through their employer and is between the ages of 19 and 26. This is the only qualifying event that will enable a dependent over the age of 19 to come back onto the policy after previous termination. Please click here to see a copy of the original Health Care Reform Notice sent to member in November 2010. Click here for link
The HIPAA form should only be filled out if you or your dependents over the age 18 wish for a spouse or child to have access to your personal health information. You or your dependents will not be able to receive claims information over the phone from Mo-Kan if you do not return this form for each family member. Click here for link
to complete for expenses obtained while covered under the Wellness Reimbursement Plan. Click here for link
This is the claim form you will need if you are going to be off work for a week or longer. You need to complete the top portion completely and the Doctor needs to complete the lower portion completely. Be sure to call the Fund Office immediately upon being off work to check your eligibility for this benefit. Click here for link
Enroll or Change Beneficiary Information, Spouse and Dependent Information on plan. Click here for link
This is the form you will need to use if you are unmarried and would like to add a child. Click here for the link
complete this form and send to MedTrak Services when you need to request a prescription reimbursement. The following are prescriptions that are not covered along with their covered alternatives. Download list here. Click here for link
Please complete this form if the members spouse has had a recent employment change and/or the spouse’s primary health insurance information has changed as well. Click here for link
Working Spouse Q & A Click Here
2020 Spouse Employment Insurance Premium Reimbursement Form Click Here
If you paid out-of-pocket for your routine vision services directly, please use this form as well an itemized provider billing in order to request reimbursement. Your yearly Routine Vision benefit is a flat $350 for adults and dependent children age 20 and over. For dependent children up to their 20th birthday, there is no dollar limit, however it is limited to 1 routine exam, 1 pairs of frames and lenses per calendar year. . Please see the SPD for further details Click here for linkPlease mail to:
Please remember, that all claims and correspondence must have the Member’s name and Unique Member ID on it. All dependents are listed under the member’s identification information and this helps us to process your claims more efficiently.