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. Be sure to complete all the info at the top of the form and sign/date at the bottom of the form. Also, please be sure to include your MO-KAN Member ID number, patient name and Date of Service on the form.
ACH Transfer Form
ACH transfer service for Retirees who are enrolled in retiree self pay.
Annual Routine Physical Examination Incentive Verification Form (2023)
Davis Vision Reimbursement Claim Form
Davis Vision Claims
Vision Care Processing Unit
P.O. Box 1525
Latham, NY 12110
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.
Dependent Eligibility Form
Complete this form if your dependent has his or her own medical health insurance or has lost his or her own medical health insurance 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.
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 Claim Form (2023)
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.
NEW Member Enrollment/Change Form
Please use this form to enroll a spouse, new baby or dependent children. Please note that additional documentation is required. Please see page 4 of the form for what to include with the enrollment form when adding different types of dependents.
This is the form you will need to use if you are unmarried and would like to add a child.
Pharmacy Mail Order Form
Use this form when ordering mail order prescriptions for the first time.
Prescription Reimbursement Form
Complete this form and send it to Elixir Solutions when you need to request a prescription reimbursement.
Spouse Employment Verification (2023)
Please complete this form if the member's spouse has had a recent employment change and/or the spouse’s primary health insurance information has changed as well.
Working Spouse Reimbursement Form (2023)
Working Spouse FAQ
WBA Reimbursement Form
Please complete for expenses obtained while covered under the Wellness Reimbursement Plan.