Forms

You will need Adobe® Acrobat® Reader® software to download any forms. Click here if you wish to have this free software installed on your computer.

Vision

VSP Member Reimbursement Form

VSP Reimbursement Claim form – Use this form to request reimbursement for vision services.  Always keep copies for your records and allow up to 30 days from the time you send until the time you receive the response.  Download this form and include an itemized bill/receipt(s) (do not staple or tape) that includes: 

  • the reference number
  • the name and telephone number of the provider
  • the date of service
  • the total billed amount
  • the name and address of the member
  • the name and relationship of the patient

Submit your VSP Reimbursement claims to:

VSP
P.O. Box 385018
Birmingham, AL  35238-0518

Dental

Dental Claim Form

download this form and give to your dentist to complete or attach an itemized bill that includes:

  • the name of the dental provider
  • the address and telephone number of the dental provider
  • the date of service(s)
  • the American Dentistry Association (ADA) code(s)
  • the billed amount for each service
  • the name of the patient

If your dental provider participates with CIGNA Dental PPO Shared Administration Plus the staff of the provider’s office will submit a claim on your behalf to CIGNA for pricing. CIGNA forwards the claims to EWTF for consideration.  It is important that you present your EWTF ID card which is also your Caremark prescription card to all CIGNA providers. By showing the card each time you visit a CIGNA provider you can be assured that your claim is priced according to the agreement and that your claim is routed to EWTF for consideration.  The EWTF group number is 3339689.

Prescriptions

Prescription Reimbursement Claim form

Use this form for prescription reimbursement.  Always keep copies for your records and allow up to 30 days from the time you send until the time you receive the response.  Download this form and include an itemized bill (do not staple or tape) that includes:

  •  the prescription number
  •  the address and telephone number of the pharmacy or NABP Number
  •  the fill date
  •  the metric quantity
  •  the medicine NDC number
  •  the total billed amount
  •  the days supply for your prescription
  •  the name of the patient

Submit your Prescription Reimbursement claims to:

CVS Caremark
P.O. Box 52196
Phoenix, AZ  85072-2196

Performance Drug List

Medical

Medical Claim Form

Use this form if your medical provider does not participate with UnitedHealthcare Choice Plus Network or if Medicare is your primary coverage. Complete forms for each patient’s medical provider and sign where indicated. Attach an itemized bill that includes:

  • the name of the medical provider
  • the address and telephone number of the medical provider
  • the date of service(s)
  • the Current Procedure Terminology (CPT) code(s)
  • the billed amount for each service
  • the name of the patient
  • attach the Medicare Explanation of Benefits

Submit your medical claims to:

Electrical Welfare Trust Fund
10003 Derekwood Lane, Ste 130
Lanham, MD 20706-4811

Enrollment Form

Completing the Enrolment Form

Life Event

Dependant Verification

Enrollment Form for Adult Dependant Coverage

Designate Beneficiary

Update Insurance Information

Statement Of Injury

Appointment of Personal Representative

Privacy Notice

Add a Dependent

Enrollment Form

Complete this form for any situation other than adding a spouse for a first marriage* or a married member adding a newborn child+. For these two scenarios use a Life Event form.

Completing the Enrollment Form

Life Event

Use this form if you are newly married* with no previous spouses on file and wish to add your spouse; if you are married and your spouse is already listed as a dependent and you are adding a newborn+.

Dependent Verification

Single member adding a child; participant working under Local 26 jurisdiction begins living separate and apart, is legally separated or divorced and pays support for natural children.

Enrollment Form for Adult Dependent Coverage

Complete this form if you wish to add or reinstate an adult dependent (between the ages of 19 and 26) to your EWTF coverage.

Designate Beneficiary

Beneficiary

Use this form to designate your beneficiary

Updating your Other Insurance Information

Insurance Update

EWTF requires this information if there are any changes as shown below:

  • you or covered family members obtaining any other health coverage
  • adding a dependent to the other coverage
  • adding or removing a type of coverage (adding dental coverage)
  • the name of the company providing the health coverage (for example, from BC/BS to ULLICO)
  • the other coverage is terminated

Claims

Statement Of Injury

This form is mailed to participants when information has been received that indicates a possible accident or injury.

Privacy

Appointment of Personal Representative

This form authorizes EWTF to give protected health information to the named individual.

Privacy Notice

This document was mailed to all eligible participants in April 2003 and to all newly eligible and reinstating participants since then.

[Definitions] [Recent News]