Mo-Kan Sheet Metal Workers Welfare Fund Claim Forms

We have all claim forms available for download in PDF format. If you do not have Adobe Acrobat Reader, you can download it here.

ACH Transfer Form: ACH transfer service for Retirees who are enrolled in retiree self pay

2010 Information Update Form: all members must complete the form and mail it to Mo-Kan, address listed below.

Claim for Reimbursement Form to complete for expenses obtained while covered under the Company Health Reimbursement Plan.

Enroll-Change Form or 2010 Update Form: Enroll or Change Beneficiary Information, Spouse and Dependent Information on plan. .

Health Claim Forms This is the form you will need to complete.

Vision Claim Forms: We do not assign vision benefits. This means that you must pay for your routine eye exams, glasses, or contacts when you purchase them. Please submit an ITEMIZED statement of your payment for the purchase along with the Vision Claim Form, directly to the MOKAN office. Use one for each member or dependent that has a claim. 

Dental Claim Forms: This is the form that your dentist will need to complete and file with our office for your dental claims. They need to mail the claims to the MOKAN office, address listed on the top of the form. 

Loss of Time Claim Forms: This is the claim form you will need if you are going to be off work for a week or longer. You need to complete the top portion completely and the Doctor needs to complete the lower portion completely. Be sure to call the Fund Office immediately upon being off work to check your eligibility for this benefit. 

HIPAA  Form,  Authorization for the Release of Protected Health Information: The HIPAA form should only be filled out if you or your dependents over the age 18 wish for a spouse or child to have access to your personal health information. You or your dependents will not be able to receive claims information over the phone from Mo-Kan if you do not return this form for each family member.

FSA Expense List: The following healthcare expenses qualify for reimbursement under a Flexible Spending Account (FSA) plan. Only healthcare expenses not reimbursed by insurance can be claimed.

HRA List: The following healthcare expenses qualify for reimbursement under a Health Reimbursement Account (HRA) plan. Only healthcare expenses not reimbursed by insurance can be claimed.

Mo-Kan Health Screen Sheet: Wellness Screening Sheet completed when participating in the Mo-Kan Sheet Metal Workers Welfare Fund Wellness Program.

Pharmacy COB Claim Form: WellDyneRx Prescription Drug Claim Form. Use this form to be reimbursed for each prescription that you purchased without your prescription card. You will be reimbursed network pharmacy rates, less co-pays.

Please mail to:
Mo-Kan Sheet Metal Workers Welfare Fund
P.O. Box 300019
Kansas City , MO 64130-0019

Please remember, that all claims and correspondence must have the Member's name and Social Security number on it. All dependents are listed under the members information and this helps us to process your claims more efficiently.