Useful CVT Forms for Members

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 placed some of our most requested forms on the website for your use and convenience.  Feel free to download them.

CVT FORMS

CVT ENROLLMENT/CHANGE E-FORM (PDF) - This form should be used for initial (fillable pdf, electronic save and submittal) enrollment in the Trust, and any changes you wish to make; e.g., address change, additions, terminations. (Printable on 8.5x14 (preferred) or 8.5x11 paper)

CVT HMO ENROLLMENT/CHANGE E-FORM (PDF) - This form should be used for initial (fillable pdf, electronic save and submittal) HMO enrollment in the Trust and any changes you wish to make; e.g., address change, additions, terminations.

CVT HMO ENROLLMENT/CHANGE PRINTABLE FORM (PDF) - This form should be used for initial (handwritten) HMO enrollment in the Trust and any changes you wish to make; e.g., address change, additions, terminations.

CVT WELLNESS GRANT APPLICATION FORM (PDF) - CVT school district based health and wellbeing program grant application.

PERSONAL CHOICE ACTIVITY FORM (WELLNESS PLAN) (PDF) - Personal choice activity form to receive wellness credits towards Anthem Blue Cross wellness plans.

CVT INFORMATION

ACTIVE EMPLOYEE ELIGIBILITY POLICY OVERVIEW (PDF)

DISTRICT PAID RETIREE GUIDELINES: HEALTH, DENTAL, VISION (PDF)

SELF PAID RETIREE GUIDELINES: HEALTH, DENTAL, VISION (PDF)

NOTICE OF PRIVACY ACT (PDF)

COBRA NOTICE (PDF)

ANTHEM BLUE CROSS FORMS

PERSONAL CHOICE ACTIVITY FORM (WELLNESS PLAN) (PDF)
MEDICARE ADVANTAGE PPO PLAN CLAIM FORM (PDF)
MEMBER CLAIM FORM (PDF)

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, 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.

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

BLUE SHIELD OF CALIFORNIA FORMS

PERSONAL CHOICE ACTIVITY FORM (WELLNESS PLAN) (PDF)
ANNUAL PREVENTIVE VISIT FORM (WELLNESS PLAN) (PDF)

MEMBER CLAIM FORM (PDF)
Usually, all providers of healthcare will bill Blue Shield of California 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, and may send the bill directly to you. In either instance, Blue Shield of California has no way of knowing about your claim. This Member Claim Form was developed to notify Blue Shield of California of any covered health service for which they have not already been billed.

MEMBER CLAIM FORM FOR SERVICES RENDERED OUTSIDE CALIFORNIA (PDF)
Usually, all providers of healthcare will bill Blue Shield of California 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, and may send the bill directly to you. In either instance, Blue Shield of California has no way of knowing about your claim. This Member Claim Form was developed to notify Blue Shield of California of any covered health service for which they have not already been billed.

PHYSMETRICS CLAIM FORM (PDF) – This form should be used for outpatient physical therapy, occupational therapy, speech therapy, chiropractic and acupuncture services.
CONTINUITY OF CARE FORM - This form is used by new and current members of a Blue Shield of California plan to request continuity of care services..

CVS CAREMARK FORMS

PRESCRIPTION REIMBURSEMENT CLAIM FORM (PDF)

This form is to provide direct reimbursement for prescriptions that were purchased without the use of your CVS Caremark card or if you have a primary prescription drug coverage with another insurance carrier.

A National Provider Identifier (NPI), a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS), is required for completion of this form. Visit www.npinumberlookup.org if you need assistance locating the correct number.

MAIL ORDER RX - ORDER FORM (PDF)

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 (PDF)

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

DELTA DENTAL CLAIM FORM

MEMBER CLAIM FORM (PDF) - In general, 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, 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.

KAISER FORMS

KAISER ENROLLMENT/CHANGE FORM (PDF)
KAISER ENROLLMENT/CHANGE FORM, SPANISH (PDF)
KAISER SENIOR ADVANTAGE ELECTION FORM (PDF)
KAISER SENIOR ADVANTAGE DISENROLLMENT FORM (PDF)

METLIFE LIFE INSURANCE FORMS

LIFE BENEFICIARY DESIGNATION (DOC)

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

METLIFE BASIC INSURANCE CERTIFICATE(PDF)

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

SUTTER HEALTH AETNA FORM

CONTINUITY OF CARE FORM (PDF)
2019 MEDICAL DEDUCTIBLE CREDIT INSTRUCTIONS - Transfer dollars accumulated in 2019 from your prior carrier toward your medical deductible.

VSP FORM

VSP OUT-OF-NETWORK CLAIM FORM(PDF)

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