Church Pension Group : Health Plans

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Health Plans

Enrollment Forms
Billing
Claims
Other

**Enrollment Forms**
Title	PDF	Mail	What is this for?	Mailing Instructions
Employee Medical and Dental Enrollment Form			To enroll a new employee or late enrollment in medical and/or dental plans	The Episcopal Church Medical Trust 445 Fifth Avenue New York, NY 10016
Enrollment Form: Retiree Group Medical and Dental			To enroll in group medical and dental plans if you are retired and enrolled in Medicare Part A and B.	Retiree Member Services The Episcopal Church Medical Trust 445 Fifth Avenue New York, NY 10016

**Billing**
Title	PDF	Mail	What is this for?	Mailing Instructions
Billing Reconciliation Form			For employers to reconcile payment differences due to enrollment changes	Email us Or fax to: 212-592-9470
Billing Reconciliaton Form -Instructions			See above

**Claims**
Title	PDF	Mail	What is this for?	Mailing Instructions
Dental Claim Form			To file a claim for dental services	Use address on your dental plan membership card
Medical Claim Form			To submit a healthcare claim	Mail to your health plan

**Other**
Title	PDF	Mail	What is this for?	Mailing Instructions
Medical/Dental Change Form			To change employee and/or billing information on individual health plans	The Episcopal Church Medical Trust 445 Fifth Avenue New York, NY 10016
Personal Health Record
Domestic Partner Affidavit			To affirm a domestic partnership for benefits purposes	Member Services The Episcopal Church Medical Trust 445 Fifth Avenue New York, NY 10016
Health Statement			For late enrollment for medical or life insurance	Health Benefit Services The Episcopal Church Medical Trust 445 Fifth Avenue New York, NY 10016
Medco By Mail Order Form			To order prescriptions by mail	Medco Health Solutions of Fort Worth PO Box 650022 Dallas, TX 75265-0022
Medical Information Authorization Form			To authorize use or disclosure of your medical information	Libby Miller, Office of Clinical Management The Episcopal Church Medical Trust 445 Fifth Avenue New York, NY 10016 Confidential Fax: (212) 592-1831

Medical Trust Disclaimer

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