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MEMBER FORMS

Member Authorization:

• Authorization to Release Health Information

Member Services:

• Declaration of Qualified Dependent Staus Form
• TeamstersCare Network Blue New England or Blue Care Elect Fitness and Weight Loss Reimbursement information
• Change of Beneficiary Form
• Request for Additional Information/Possible Third Party Claim Form
• Change of Address Form
• New Smoking Cessation Form

Retirees:

• Automatic HealthCare Deduction for TeamstersCare Retirees Form

Pharmacy:

• Prescription Drug Reimbursement Form – Active, NCH, Early Retirees
• Medco mail-order form
• Prescription Drug Direct Payment Claim Form – Retirees Age 65 and over
• TeamstersCare Medication Prior Authorization Request Form
  • Q&A About Prior Authorization

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