Forms
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⇒ Don't forget to sign the forms!
Medical Claim form - use this form if your medical provider does not participate with OneNet PPO. 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; and
- the name of the patient
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; and
- the name of the patient
If your medical or specialty dental provider participates with OneNet PPO the staff of the provider's office will submit a claim on your behalf to OneNet for pricing. OneNet 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 OneNet providers. By showing the card each time you visit an OneNet PPO 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 AM0011.
