Forms & Documents
Claims
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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
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Health Fund COBRA Continuation Coverage Rights
A document containing information about your COBRA continuation coverage rights.
Family - Dependents
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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
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Caremark Formulary Exclusions 2021
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
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Coronavirus Short-Term Disability Claim Form
Use this form to notify TeamCare of a short-term disability due to coronavirus (COVID-19). -
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
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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
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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.
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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
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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
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2019
Use these links to access the Summary Annual Reports for active and retiree plans.
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2018
Use these links to access the Summary Annual Reports for active and retiree plans.
Electronic Funds Transfer
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Electronic Payment/Remittance Authorization Agreement
Complete and submit this form to authorize electronic payments.
Predetermination of Benefits
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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.
Legal
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Subrogation Form
Complete this form if another person caused or may be responsible for your injury or illness, in order to help administer your claims. -
Health Fund Trust Agreement Document
This document details the trust agreement between Central States Funds, local unions, members, and employers.
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Central States, Southeast and Southwest Areas Health and Welfare Fund Active Plan (Grandfathered)
The plan document for the grandfathered Active Plan. -
Central States, Southeast and Southwest Areas Health and Welfare Fund Active Plan Document (Non-Grandfathered)
The plan document for the non-grandfathered Active Plan. -
Central States, Southeast and Southwest Areas Health and Welfare Fund Retiree Plan Document
The plan document for the Retiree Plan. -
Central States, Southeast and Southwest Areas Health and Welfare Fund UPS Freight Option A Plan Document
The plan document for the UPS Freight Option A plan. -
Central States, Southeast and Southwest Areas Health and Welfare Fund UPS Retiree Plan
The plan document for the UPS Retiree Plan. -
Central States, Southeast and Southwest Areas Health and Welfare Fund UPS Retiree RU Plan Document
The plan document for the UPS Retiree RU Plan. -
Central States, Southeast and Southwest Areas Health and Welfare Fund UPS Retiree RV Plan Document
The plan document for the UPS Retiree RV Plan.