Forms & Documents

Claims

  • Subrogation Form
    Complete this form if someone covered by your plan has suffered an injury that was, or may have been, caused by another person.

COBRA

  • Health Fund COBRA Continuation Coverage Rights
    A document containing information about your COBRA continuation coverage rights.

Family - Dependents

  • Alternate Address Request
    Complete this form to designate an address other than the participant address that will be used for all explanation of benefits statements, correspondence, and claim checks.
  • Alternate Address & Restrict Use and Disclosure of Protected Health Information
    Complete these forms to designate an address other than the participant address that will be used for all explanation of benefits statements, correspondence, and claim checks and to restrict the use and disclosure of your protected health information or protected health information of your minor child or to add a password of your choosing.
  • Adult Child Other Insurance Information
    Use this form to notify TeamCare if any other insurance coverage exists for an adult child.

Prescription

  • Caremark Standard Control Formulary 2025

    This document contains a list of non-specialty medications, organized by drug class, that are covered or excluded by your plan’s formulary.

  • Caremark Advanced Control Specialty Formulary 2025

    This document contains a list of specialty medications, organized by drug class, that are covered or excluded by your plan’s formulary.

  • Caremark Mail Service Order Form
    Use this form to order new prescriptions, or order refills, through the CVS Caremark™ Mail Order Pharmacy.
  • Caremark Prescription Reimbursement Claim Form
    NATA65P qualifying pensioners should use this form to request reimbursement for prescriptions under the NATA65P/Medicare Part D benefit.
  • Prescription Drug Claim
    Members covered by active or retiree plans should use this form to request reimbursement for prescription claims paid out-of-pocket, or for Coordination of Benefit prescription claims.
  • TeamCare Rx Pharmacies
    A list of national pharmacy chains that are a part of the CVS Caremark TeamCare Rx Retail Program.

Short-Term Disability

  • Short-Term Disability Initial Report of Disability
    Use this form to notify TeamCare of a short-term disability due to a non-work-related injury or illness or inability to work due to pregnancy.
  • Short-Term Disability Continuation
    Complete this form to notify TeamCare of a continued period of disability.
  • Application for Extension of Coverage
    Use this form to apply for an extension of health coverage for your disabling condition. 

Retiree Health Plans

Life Insurance

  • Life Insurance Preference Beneficiary Form
    This form should be completed by a surviving beneficiary or executor of a member’s estate to claim the TeamCare life insurance benefit when the deceased participant did not designate a beneficiary.
  • Health Fund Dismemberment Application Form
    Complete this form in the event of accidental dismemberment from a bodily injury.
  • Health Fund Notice of Claim for Death and Accidental Death Benefits

    Use this form to apply for death and accidental death benefits.

  • Life Insurance Beneficiary Designation Form
    Complete this form to choose a beneficiary for your TeamCare Life Insurance Benefit.
  • Health Fund Notice of Claim for Total & Permanent Disability of Premium Benefits
    Use this form to apply for total and permanent disability/waiver of premium benefits.

HIPAA

  • Notice of Privacy Practices

    This document describes how medical information about you may be used and disclosed, and how you can access this information.

  • Authorization to Allow Use and Disclosure of Protected Health Information
    Complete this form to authorize the use and disclosure of your protected health information or the protected health information of your minor child.
  • Request to Restrict Use and Disclosure of Protected Health Information
    Complete this form to restrict the use and disclosure of your protected health information or the protected health information of your minor child or to designate a password of your choosing.
  • Alternate Address Request

    Complete this form to designate an address other than the participant address that will be used for all explanation of benefits statements, correspondence, and claim checks.

  • Alternate Address & Restrict Use and Disclosure of Protected Health Information
    Complete these forms to designate an address other than the participant address that will be used for all explanation of benefits statements, correspondence, and claim checks and to restrict the use and disclosure of your protected health information or protected health information of your minor child or to add a password of your choosing.
  • Request a Copy of Health and Welfare Information

    Complete this form to request a copy of your or protected health and welfare information or the protected health information of your minor child.

Annual Reports

Electronic Funds Transfer

  • Electronic Payment/Remittance Authorization Agreement
    Complete and submit this form to authorize electronic payments.

Predetermination of Benefits

  • Medical Predetermination of Benefits Request Form
    Use this form to request a Predetermination of Benefits. The form also includes a list of medical procedures or devices where a Predetermination of Benefits is required or recommended.
  • Medical Predetermination of Benefits Request Form – Central States Funds Employee
    Use this form to request a Predetermination of Benefits for a Central States Funds employee with the member ID prefix FFF. The form also includes a list of medical procedures or devices where a Predetermination of Benefits is required or recommended.