Claim Forms

Mo-Kan Sheet Metal Workers Welfare Fund Claim Forms

We have all claim forms available for download in PDF format. If you do not have Adobe Acrobat Reader, you can download it here.

Accident Questionnaire

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 info at the top of the form and sign/date at the bottom of the form. Also please be sure to include your MoKan Member ID number, Patient name and Date of Service on the form. Click here for link

ACH Transfer Form

ACH transfer service for Retirees who are enrolled in retiree self pay. Click here for link

Dependent Eligibility Form

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

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 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

WBA Reimbursement Form

to complete for expenses obtained while covered under the Wellness Reimbursement Plan. Click here for link

Loss of Time Claim Form

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

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. Click here for link

Notary Form

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

Prescription Reimbursement Form

Complete this form and send to Elixir Solutions when you need to request a prescription reimbursement.   Click here for link

Pharmacy Mail Order Form

Use this form when ordering mail order prescriptions for the first time. Click here for link

Spouse Employment Verification

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 FAQs and Reimbursement Form

Working Spouse FAQ    Click Here

2021 Spouse Employment Insurance Premium Reimbursement Form Click Here

2022 Spouse Employment Insurance Premium Reimbursement Form Click Here

Davis Vision

Davis Vision Claim Form Click Here
Mailing Address:
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.