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Forms and Information

We know that it is not always convenient to go by your district office or come by CVT's office when you need a form; so we have put some of our most requested forms on the website for your use and convenience.

CVT FORMS:

CVT INFORMATION

ANTHEM BLUE CROSS FORMS:

  • MEMBER CLAIM FORM

    Usually, all providers of healthcare will bill Anthem Blue Cross for services rendered to you and your enrolled dependents. This is the preferred procedure. Sometimes, a physician may not bill us or an ambulance company, for example, may send the bill directly to you. In either instance, Anthem Blue Cross has no way of knowing about your claim. This Member Claim Form was developed to notify Anthem Blue Cross of any covered health service for which they have not already been billed.

  • SECONDARY CLAIM FORM

    This form should be used if you have primary prescription drug coverage with another insurance carrier and a High Deductible Health Plan (HDHP) or Bronze Plan as secondary through CVT.

  • CONTINUITY OF CARE FORM
  • UNDERSTANDING YOUR EXPLANATION OF BENEFITS (EOB)
  • MEMBER AUTHORIZATION FORM TO RELEASE INFORMATION (HIPAA)

BLUE SHIELD FORMS:

  • MEMBER CLAIM FORM

    Usually, all providers of healthcare will bill Blue Shield for services rendered to you and your enrolled dependents. This is the preferred procedure. Sometimes, a physician may not bill us or an ambulance company, for example, may send the bill directly to you. In either instance, Blue Shield has no way of knowing about your claim. This Member Claim Form was developed to notify Blue Shield of any covered health service for which they have not already been billed.

CVS CAREMARK FORMS:

  • STANDARD CLAIM FORM

    This form is to provide direct reimbursement for prescriptions that were purchased without the use of your CVS Caremark card.

  • SECONDARY CLAIM FORM

    This form should be used if you have primary prescription drug coverage with another insurance carrier.

  • MAIL ORDER RX - ORDER FORM

    To receive your prescriptions by mail enclose your original, written prescription and payment with this form. Ask your doctor to write a mail order prescription to maximize the supply as allowed by your plan. Remember mail order is a 90-day supply. Your Mail Order should be mailed to: CVS Caremark, PO Box 659541, San Antonio, TX 78265-9541.

  • YOUR MAIL SERVICE BROCHURE

    This brochure provides information in regards to the Mail Order application of your prescription benefit program.

DELTA DENTAL CLAIM FORM:

  • MEMBER CLAIM FORM

    Usually, all providers will bill Delta Dental for services rendered to you and your enrolled dependents. This is the preferred procedure. Sometimes, a Dentist may not bill us or, for example, and may send the bill directly to you. In these instances, Delta Dental has no way of knowing about your claim. This Member Claim Form was developed to notify Delta Dental of any covered service for which they have not already been billed.

HEALTHCOMP CLAIM FORM:

  • MEMBER CLAIM FORM

    Usually, all providers of healthcare will bill Healthcomp for services rendered to you and your enrolled dependents. This is the preferred procedure. Sometimes, a physician may not bill us or an ambulance company, for example, may send the bill directly to you. In either instance, Healthcomp has no way of knowing about your claim. This Member Claim Form was developed to notify Healthcomp of any covered health service for which they have not already been billed.

KAISER FORMS:

METLIFE LIFE INSURANCE FORMS:

VSP FORM: