Do You Need a Form?
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UMWA Health and Retirement Funds

Do You Need a Form?

The list of forms below includes two of the most common medical forms used by physicians, hospitals and other facilities. It also includes other forms, such as for eye exams, mail order prescription drugs and change of address. If you do not see the form you are looking for, please call the Funds' Call Center at: 1-800-291-1425

Medical

CMS 1500: Used for physician billing

UB04: Used for hospital, rehabilitation centers, surgery centers and clinic billing

 Vision

CBF and 1992 Benefit Plan Form

 

 Pharmacy

 

Caremark Claim Form

 Other

      Change of Address

 
Authorization for the Use and Disclosure of Protected Health Information