Useful CVT Forms for Districts and Chapters

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

• CVT ENROLLMENT/CHANGE E-FORM

This (fillable pdf, electronic save and submittal) form is used for initial enrollment in the Trust, and any changes an employee wishes to make; e.g., address change, additions, terminations and is forwarded to your District office.

• CVT ENROLLMENT/CHANGE PRINTABLE FORM

This handwritten form is used for initial enrollment in the Trust, and any changes your employees wish to make; e.g., address change, additions, terminations and is forwarded to your District office.

• CVT HMO ENROLLMENT/CHANGE E-FORM

This (fillable pdf, electronic save and submittal) form is used for initial HMO enrollment in the Trust and is forwarded to the employee’s District office.

• CVT HMO ENROLLMENT/CHANGE PRINTABLE FORM

This handwritten or PDF form is used for initial HMO enrollment in the Trust and is forwarded to the employee’s District office.

• REMITTANCE FORM FOR CHANGES

Remittance form for changes to an employee’s plan.

• REMITTANCE FORM FOR ADDITIONS

Remittance form for additions to an employee’s plan.

• REMITTANCE FORM FOR TERMINATIONS

Remittance form for terminations to an employee’s plan.

CVT Information

• NOTICE OF PRIVACY ACT

ANTHEM BLUE CROSS FORMS

• MEMBER CLAIM FORM

Usually, healthcare providers 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 Anthem Blue Cross or an ambulance company, for example, and 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 a district employee has 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 CLAIM FORM

• MEMBER CLAIM FORM

Typically, all healthcare providers will bill Blue Shield of California for services rendered to the employee and their enrolled dependents. This is the preferred procedure. Sometimes, a physician may not bill Blue Shield of California or an ambulance company, for example, and 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 a CVS Caremark card.

• SECONDARY CLAIM FORM

This form should be used if and employee has primary prescription drug coverage with another insurance carrier.

• MAIL ORDER RX - ORDER FORM

To receive prescriptions by mail, the employee should enclose their original written prescription and payment with this form. The employee needs to ask the doctor to write a Mail Order prescription to maximize the supply as allowed by their plan. Remember mail order is a 90-day supply. The employee 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 employee prescription benefit program.

DELTA DENTAL CLAIM FORM

• MEMBER CLAIM FORM

In general, all dental providers will bill Delta Dental for services rendered to employees and their enrolled dependents. This is the preferred procedure. Sometimes, a Dentist may not bill Delta Dental or, for example, may send the bill directly to the employee. In these instances, Delta Dental has no way of knowing about their 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

As a rule, all healthcare providers will bill Healthcomp for services rendered to an employee and their enrolled dependents. This is the preferred procedure. Sometimes, a physician may not bill us or an ambulance company, for example, and may send the bill directly to the employee. In either instance, Healthcomp has no way of knowing about their 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

Employees should fill this form out to designate a life beneficiary or change their 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 an employee uses an Out-Of-Network Provider.