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 Payee Request
    Complete this form to request an alternate payee for the benefits you receive.
  • Adult Child Other Insurance Information
    Use this form to notify TeamCare if any other insurance coverage exists for an adult child.

Prescription

  • Caremark Formulary Exclusions 2022
    This document contains a list of medicines by drug class that have been removed from your plan’s formulary, or the list of prescriptions that are covered by your plan.
  • 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 purposes.
  • 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

  • Retiree Health Plan Postponement Form
    Complete this form to postpone Retiree Health Plan coverage to a later date, if you have other insurance coverage in effect.
  • Retiree Health Plan Reinstatement Form
    Complete this form to reinstate your Retiree Health Plan benefits if you have previously postponed coverage.
  • Retiree New Spouse Coverage Request Form
    Use this form to request Retiree Health Plan coverage for your new spouse.
  • Retiree Health Plan Benefits and Medicare
    View this document to help determine if you are eligible or remain eligible for the Retiree Health Plan.

Life Insurance

  • Life Insurance Preference Beneficiary Form
    This form should be completed by a surviving beneficiary or executor of a member’s estate upon their death in order to designate a life insurance 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

  • Authorization to Allow Use and Disclosure of Protected Health Information
    Complete this form to authorize the use and disclosure of your or another member’s protected health information.
  • Notice of Privacy Practices
    This notice describes how medical information about you may be used and disclosed, and how you can access this information.
  • Request to Restrict Use and Disclosure of Protected Health Information
    Complete this form to restrict the use and disclosure of your or another member’s protected health information.
  • Request a Copy of Health and Welfare Information

    Use this form to request a copy of your or another member’s health and welfare information.

Annual Reports

Machine Readable Files

  • Blue Cross Blue Shield

    These files (in-network rate file and out-of-network allowed amount file) provide rates, allowed amounts, and billed charges for covered items and services.

    These files are extremely large and the speed to download may take significant time.

  • US Imaging

    This file provides standard charges for covered items and services.

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.