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.

Dependent Eligibility Form: Complete this form only if your dependent has lost his/her own medical health insurance through their employer and is between the ages of 19 and 26.  This is the only qualifying event that will enable a dependent over the age of 19 to come back onto the policy after previous termination. Please click here to see a copy of the original Health Care Reform Notice sent to member in November 2010.

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.

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

Loss of Time Claim Form: 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. 

Loss of Time Continuation Form: this form needs to be completed in order to continue your loss of time benefits with the Fund.

New Member Enrollment/Change Form: Enroll or Change Beneficiary Information, Spouse and Dependent Information on plan. .

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.

Pharmacy Mail Order Form: complete this form and send to Welldyne RX when you need to request a new mail order prescription.

Spouse EmploymentVerification: Please complete this form if the members spouse has had a recent employment change and/or the spouse’s primary health insurance information has changed as well.

Spousal Reimbursement Form 2011 or 2012: Please complete the attached form to request the reimbursement of a spouse’s primary health insurance premium.  This form must be submitted along with proof of premium payment either with copies of pay stubs or a letter from HR confirming premium amount paid.

Vision Claim Forms: If you paid out-of-pocket for your routine vision services directly, please use this form as well an itemized provider billing in order to request reimbursement.  Your yearly Routine Vision benefit is a flat $300, please see the SPD for further details.

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 Unique Member ID on it.  All dependents are listed under the member’s identification information and this helps us to process your claims more efficiently.