Updated: 12-06-12

Form		Purpose
Important Notes About Your Coverage		Information about your coverage
Affidavit of Next of Kin(.doc)		Legal attestation to next of kin
Affidavit of Surviving Spouse(.doc)		Legal attestation to surviving spouse
ARRA Premium Reduction Election Form (for former employees of organizations with 1 – 19 employees)		Continuation of coverage reduction election form for individuals who lost employment between 9/1/08 and 12/31/09.
Authorization to Release Information		Legal attestation to release information
Authorization to Release Information - Revocation		Revocation of information release
Authorization to Release Information (Term of Coverage)		Legal attestation to release information following termination of coverage
Coordination of Benefits Questionnaire		Establishes whether or not Coordination of Benefits applies
Chiropractic Plan of Treatment Form		Form for Chiropractic Benefits
Group Enrollment Form		Enrollment form for subscribers
Incapacitated Dependent Form		Allows dependent children to continue on parents’s coverage when they would ordinarily be dropped
Nongroup Coverage Application and Change Form		Main enrollment form for individuals not enrolled as part of a group
Prescription Reimbursement/Drug Claim Form		Used by members NOT covered under VT Blue 65 to get reimbursed for out-of-pocket prescription expenses
Prescription Reimbursement Form (VT Blue 65 Members)		Used by VT Blue 65 members to get reimbursed for out-of-pocket prescription expenses
Prior Approval - Medical Services Comprehensive Procedure and CPT Code Listing		Medical Services requiring Prior Approval
Prior Approval - DME, Orthotics, and Prosthetics Comprehensive Procedure and CPT Code Listing		DME Orthotics and Prosthetics Requiring Prior Approval
Prior Approval Request & Referral Authorization Form for Medical Services and DME		Form for Medical Services, Durable Medical Equipment (DME), Orthotics and Prosthetics requiring Prior Approval
Prior Approval Forms (drug-specific) and Guidelines for Prescription Drugs		Prescription Drugs requiring Prior Approval
Safety Net Application and Change Form		Application form for a very limited number of individuals who lost their coverage through a specific set of circumstances
Statement of Domestic Partnership		Legal attestation used to obtain coverage for domestic partner
Subscriber Claim Form		Form for members to get reimbursed for claims where such was not filed for them

BlueCare Access

 Forms for Catamount & VT Blue 65 Members 

Form		Purpose
CMS Creditable Coverage Guidance		Important notice concerning prescription drug coverage
Catamount Bluesm Enrollment Application		Form to enroll in Catamount Blue
CMS Creditable Coverage Guidance		Important notice concerning prescription drug coverage
CMS Model Creditable Coverage Notices (Word Doc)		Important notice concerning prescription drug coverage
CMS Model Non-Creditable Coverage Notices (Word Doc)		Important notice concerning prescription drug coverage
CMS Model Personalized Creditable Coverage Notices		Important notice concerning prescription drug coverage
Nongroup Subscriber Medicare Supplement Application and Change Form		Form to be used for subscription changes