Forms & publications

Enrollment Forms  Other Documents and Forms   Notices    Newsletter

All forms are provided in PDF format unless otherwise noted. The free Adobe® Reader® software is required.

ENROLLMENT FORMS

Authorization to Release Information (HIPAA) - updated June 2010
This form allows participants age 18 and older to allow claims information to be released to one or more designated persons.

Basic Plan Acknowledgment Form - updated April 2010

Participants who have elected to enroll in the MUST Basic plan will be asked to sign this affidavit acknowledging that they understand the Basic plan's limitations.

Change Form - updated April 2010
Use this form to report changes in name, address, or marital status; to terminate a dependent’s coverage; report a change from active to retiree status; or to change beneficiaries for the Basic life insurance included with the MUST medical benefit.  Remember, you must submit this form to your clerk or HR/payroll person.  Do not submit it directly to MUST.

HSA Acknowledgment Form - updated April 2010

Participants who have elected to enroll in the MUST HSA-Qualified Plan will be asked to sign this affidavit acknowledging that they understand related limitations.

Declaration of Domestic Partner Form - updated April 2010
This form must be notarized and submitted to MUST to establish eligibility for a common-law spouse or adult partner.

Employee Benefit Election Form - updated April 2010

Use this form to make changes in plan elections during the annual Open Enrollment Period.  Do not use this form to add or drop dependents; use the Change Form instead. 

Employee Termination Form - updated March 2009
Use this form to terminate coverage for employees/trustees. (To terminate a dependent’s coverage, use the Change Form.)

Enrollment Form - updated April 2010
Use this form to enroll new participants and their dependents in health, dental, and/or vision coverage, and to designate beneficiaries for the basic life insurance included with the MUST medical benefit.

Click here to see a sample form with tips for completing each field.

Group Health Statement Form - updated April 2010

These forms are used for participants in new groups, or for late enrollees in existing groups.

Life Insurance Enrollment and Beneficiary Form - updated April 2010

The Option 1 portion of the form is required for all participants in groups that offer Option 1 (employer-paid) life insurance. The Option 2 portion of the form is used only for participants who elect Option 2 (employee-paid) life insurance. Beneficiaries for Option 1 and Option 2 coverage are also designated or changed on this form.

Medical History Statement (Standard Life Insurance)
Use this form for life insurance late enrollees and for participants who wish to apply for life insurance amounts above the guaranteed-issue amount.

Value Medical Plan Acknowledgment - updated May 2010

Participants who have elected to enroll in the Value Plan will be asked to sign this affidavit acknowledging that they understand related limitations.

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OTHER DOCUMENTS AND FORMS

Accident Questionnaire - updated June 2010

This form may be used for injury claims to determine whether some of the costs can be paid with no deductible under the MUST accident benefit.

Caremark Pharmacy Benefit Form

Clicking this link will display another page where you'll find links to Caremark forms and publications.

HSA-Qualified Plan RX Claim Form - updated June 2010

Use this form to submit prescription drug claims when covered under the HSA-Qualifying Plan.

Coordination of Benefits (COB) Questionnaire - updated June 2010

This form is completed annually and is used to inform MUST of any other coverages that you or your dependents may have.

County Health Department Claim Form - PDF version

or MS Word version  - updated June 2010

County health department staff can fill out this form and submit to MUST for payment after administering immunizations to MUST participants.

District Quote Data (for MUST representatives) - updated December 2009
This document is used for groups who are not currently insured through MUST and are seeking a quote.

Domestic & International Claim Form - updated June 2010

Use this form to submit a claim to MUST when you have paid a provider up front for medical or preventive services.

Frequently Needed Numbers List  - updated June 2010

This handy sheet includes telephone numbers for various questions you might have about eligibility, claims, pharmacy benefits, and other issues.

Health Fair Claim Form - updated June 2010

Use this form to submit claims when you have attended a health fair and are seeking reimbursement.

HSA Payroll Deduction Authorization Form
Enrollees in the HSA-qualified Consumer Driven Health Plan may provide this form to his/her employer to authorize payroll deductions to fund a Health Savings Account.

Long Term Disability (LTD) Claim Form

Use this form to claim long term disability (LTD) benefits.

Preventive Benefits Flyer for 2009-2010 - updated June 2010

This flyer helps MUST participants understand the difference between preventive and medical claims, and provides an overview of the MUST preventive benefit package including new colon cancer screening benefits. The flyer is designed to be folded in half, booklet-style.

Retiree Brochure - updated August 2009

If you currently have MUST health benefits and are thinking of retiring, this brochure is for you! It also answers some common questions from those who have both MUST and Medicare coverage.

Sample Claim Explanation of Benefits (EOB) Form

This PDF document helps to explain the MUST EOB form that participants receive after a claim has been processed.

Travel Reimbursement Form - updated June 2010

Use this form to request reimbursement for eligible, medically necessary out-of-state travel costs.  The second page explains eligible expenses and exclusions.

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MUST NEWSLETTER

THE MUST READ

This is a helpful resource that includes information about changes to benefits, articles related to health and wellness, and detailed answers to frequently asked questions. 

NOTICES

COBRA Continuation Rights Notice
This notice is mailed to participants upon initial enrollment describing their right to continue coverage under COBRA if they lose eligibility for group coverage.

HIPAA Notice
This notice is provided to newly enrolled participants to describe the privacy protections provided under HIPAA laws.

Foreign Travel Letter (sample)

If you plan to travel outside the U.S., call the Claims Administration office (1-877-714-5556) for guidance on seeking healthcare from foreign providers. They can mail you a letter that explains the requirements.

Women’s Health and Cancer Rights Notice

This notice is provided annually to participants to discuss certain benefits that are guaranteed under HIPAA laws.

Links to documents available elsewhere on this site:

• MUST Summary Plan Description
• MUST Benefit Summary
• Kalispell Benefit Summary

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