California's Valued Trust

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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 ENROLLMENT/CHANGE FORM

  This form should be used for initial enrollment in the Trust, and any changes you wish to make; e.g., address change, additions, terminations.

• CVT HMO ENROLLMENT/CHANGE FORM

  This form should be used for initial HMO enrollment in the Trust, and any changes you wish to make; e.g., address change, additions, terminations.

• DISABLED DEPENDENT CERTIFICATION FORM

  A dependent child who is incapable of self-support due to mental or physical handicap may be eligible for continued coverage as a disabled dependent. This form accompanied by a physician's statement needs to be turned in to start the qualification process.

• DECLARATION OF DOMESTIC PARTNERSHIP

  This form needs to accompany the CVT Enrollment Form whenever you add a Domestic Partner to your benefits.

• PERSONAL CHOICE ACTIVITY FORM

  Personal choice activity form to receive wellness credits towards Anthem Blue Cross wellness plans

• TERMINATION OF DOMESTIC PARTNERSHIP

  This form needs to accompany the CVT Enrollment Form whenever you delete a Domestic Partner from your benefits.

• REMITTANCE FORM FOR CHANGES

  Remittance form for changes to your plan.

• REMITTANCE FORM FOR ADDITIONS

  Remittance form for additions to your plan.

• REMITTANCE FORM FOR TERMINATIONS

  Remittance form for terminations to your plan.

CVT INFORMATION

• ACTIVE EMPLOYEE ELIGIBILITY POLICY

• ACTIVE EMPLOYEE ELIGIBILITY POLICY RIDER

• NOTICE OF PRIVACY ACT

  Notice of Privacy Practices for the use and disclosure of private health 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.

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:

• KAISER ENROLLMENT/CHANGE FORM

• KAISER ENROLLMENT/CHANGE FORM, SPANISH

• KAISER SENIOR ADVANTAGE ELECTION FORM

• KAISER SENIOR ADVANTAGE DISENROLLMENT FORM

METLIFE LIFE INSURANCE FORMS:

• LIFE BENEFICIARY DESIGNATION

  Fill this form out to designate your life beneficiaries or change your beneficiaries.

• METLIFE BASIC INSURANCE CERTIFICATE

  This certificate describes the benefits available to CVT members with life insurance coverage.

VSP FORM:

• VSP OUT-OF-NETWORK CLAIM FORM

  This form is to provide direct reimbursement when you use an Out-Of-Network Provider.