Site Map 2008 Life Plan - Download the 2008 Group Life Insurance Benefits Plan. 2008 Benefits Summary - Download the benefits summary. Coordination of Benefits Form The coordination of benefits form will be replacing the annual claim form you are used to receiving. Please fill this out regardless of whether you have other insurance or if you already sent in an annual claim form. Claim for Reimbursement Form to complete for expenses obtained while covered under the Company Health Reimbursement Plan. 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. FAQ: Frequently Asked Questions. Health Claim Forms This is the form you will need to complete. HIPPA 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 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. 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. Mo-Kan Health Screen Sheet: Wellness Screening Sheet completed when participating in the Mo-Kan Sheet Metal Workers Welfare Fund Wellness Program. Summary Plan or PDF version Summary Plan 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.
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