Accident Questionnaire 
Complete this form when medical claims are pending for accident information. Be sure to complete all the information at the top of the form and sign/date. INCLUDE | Your Mo-Kan ID number, patient name and Date of Service.

Retiree Verification Form - ACH Preauthorization
ACH Authorization Agreement for Retirees who are enrolled in Retiree self-pay.

Dependent Add Form | If applicable, include copies of other coverage insurance cards

This form is used to add a new Dependent. Please complete one Dependent Add Form for each dependent being enrolled on the Plan. Be sure to include any and all supporting documents required. 

Dependent Coverage/Employment Verification Form
Complete this form if you need to update your enrolled Dependents other primary coverage and/or employment status. 

** If your Dependent Child has lost their own medical coverage 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 **

EyeMed Reimbursement Form for Out of Network Claims

Health Coverage Responsibility Form | Must be notarized 
Complete this form if you are enrolling a child, and you were never been married to the dependent's mother/father.

HIPAA Form — Authorization for the Release of Protected Health Information
The HIPAA form should only be filled out if you or your dependents over the age of 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.

Loss of Time & Enhanced Loss of Time Claim Form
You must complete the top portion completely and the physician must complete the lower portion completely. Be sure to call the Fund office immediately upon being off work to check your eligibility for this benefit.

New Member Enrollment Form

Beneficiary Update Form

Prescription Reimbursement Form | Through Capital Rx

Spousal Reimbursement Claim Form | 2026

Reimbursement Claim Form | Please use for: WBA, Gym, and Prescription Coordination of Benefits reimbursement requests