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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:
Submit your VSP Reimbursement claims to:
P.O. Box 385018
Birmingham, AL 35238-0518
download this form and give to your dentist to complete or attach an itemized bill that includes:
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.
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:
Submit your Prescription Reimbursement claims to:CVS Caremark P.O. Box 52196 Phoenix, AZ 85072-2196
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:
Submit your medical claims to:Electrical Welfare Trust Fund 10003 Derekwood Lane, Ste 130 Lanham, MD 20706-4811
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.
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+.
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.
Complete this form if you wish to add or reinstate an adult dependent (between the ages of 19 and 26) to your EWTF coverage.
Use this form to designate your beneficiary
EWTF requires this information if there are any changes as shown below:
This form is mailed to participants when information has been received that indicates a possible accident or injury.