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.
This form should be used for initial enrollment in the Trust, and any changes you wish to make; e.g., address change, additions, terminations.
OVERAGE DEPENDENT CERTIFICATION FORM
This form needs to be filled out for a dependent 19 through 24 and accompanied with the necessary forms of proof as indicated on the form.
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.
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 to your plan.
Remittance form for additions to your plan.
REMITTANCE FORM FOR TERMINATIONS
Remittance form for terminations to your plan.
This form needs to accompany the Remittance form for terminations when employees are terminted involuntarily.
Notice of Privacy Practices for the use and disclosure of private health information.
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.
This form is to provide direct reimbursement for prescriptions that were purchased without the use of your CVS Caremark card.
This form should be used if you have primary prescription drug coverage with another insurance carrier.
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.
This brochure provides information in regards to the Mail Order application of your prescription benefit program.
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.
This enrollment form needs to be filled out in addition to the CVT Enrollment Form when you are signing up for Pacificare coverage.
SECURE HORIZONS ENROLLMENT FORM
Secure Horizons Group Retiree Medicare Advantage (MA) plan enrollment form.
SECURE HORIZONS DISENROLLMENT FORM
Secure Horizons Group Retiree Medicare Advantage (MA) plan disenrollment form.
This enrollment form needs to be filled out in addition to the CVT Enrollment Form when you are signing up for life coverage.
Fill this form out to designate your life beneficiaries or change your beneficiaries.
This form is to provide direct reimbursement when you use an Out-Of-Network Provider.