Do You Need a Form?
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UMWA Health and Retirement Funds

Do You Need a Form?

The list below includes two of the most common medical forms used by physicians, hospitals and other facilities. It also includes other forms for eye exams, mail order prescription drugs and change of address. If you do not see the form you need, 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

1993 Benefit Vision Claim Form

 

Pharmacy 

Caremark Claim Form

Mail Order Prescription Form

Preferred Product Program Exception​

Brand Over Generic Medical Necessity Form


Other

Change of Address

 

Authorization for the Use and Disclosure of Protected Health Information

 

 

Advance Directive: Find your state

 

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