Health Plans

Enrollment Forms

Title What is This For? Contact Information
Retiree Group Medical and Dental Enrollment Form - 2018 To enroll in Medicare Supplement and dental plans if you are retired and enrolled in Medicare Part A and B.

The Episcopal Church Medical Trust
19 East 34th Street
New York, NY 10016

Retiree Group Medical and Dental Enrollment Form - 2017 To enroll in Medicare Supplement and dental plans if you are retired and enrolled in Medicare Part A and B.

The Episcopal Church Medical Trust
19 East 34th Street
New York, NY 10016

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
19 East 34th Street
New York, NY 10016

Seminarian Medical and Dental Open Enrollment Form To enroll seminarians in medical and/or dental plans

The Episcopal Church Medical Trust
19 East 34th Street
New York, NY 10016

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Billing

Title What is This For? Contact Information
Billing Reconciliation Form For employers to reconcile payment differences due to enrollment changes

Email: billingrecon@cpg.org
Or fax to:
212-592-9470

Billing Reconciliation Form -Instructions Billing Reconciliation (Instructions)

Email: billingrecon@cpg.org

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Claims

Title What is This For? Contact Information
Medical Claim Form To submit a healthcare claim

Mail to your health plan

Dental Claim Form To file a claim for dental services

Use address on your dental plan membership card

Colleague Group Claim Form Colleague Group Reimbursement Claim Form

The Episcopal Church Medical Trust
19 East 34th Street,
New York, NY, 10016;
or fax to (212) 251-8891

Express Scripts Prescription Drug Claim Form To submit a claim for prescription drugs

Express Scripts, Inc.
P.O. Box 66583
St. Louis, MO 63166-6583
ATTN: NGC STD ACCTS

Medicare Part D Prescription Drug Claim Form Prescription Claim Form for Medicare Part D

Express Scripts
ATTN: Medicare Part D
P.O. Box 14718
Lexington, KY 40512-4718
FAX: (608) 741-5483

EyeMed Out of Network Vision Services Claim Form Out of Network Vision Services Claim Form

EyeMed Vision Care
Attn: OON Claims
P.O. Box 8504
Mason, OH 45040-7111

International Travel Claim Submission Form-Medicare Supplement Plans Only Submitting international travel claims for Retirees participating in Medicare Supplement plans only

Episcopal Church Medical Trust
Travel Protection Benefit Coordinator
PO Box 2745
New York, NY 10163

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Medical Forms

Title What is This For? Contact Information
Statement of Dissolution of Domestic Partnership Notification to the Episcopal Church Medical Trust of the termination of a domestic partnership

Member Services
The Episcopal Church Medical Trust
19 East 34th Street
New York, NY 10016

Child Affidavit To enroll your Child for coverage outside of the initial or annual Open Enrollment period

RETURN THIS COMPLETED FORM TO
Medical Trust:
The Episcopal Church
19 East 34th Street
New York, NY 10016
Fax: (212) 592‐4234
Email: mtcustserv@cpg.org

Medical Information Authorization Form To authorize use or disclosure of your medical information

JoAnn Goetz,
Clinical Management
The Episcopal Church Medical Trust
19 East 34th Street
New York, NY 10016
Confidential Fax: (212) 592-1831

Domestic Partner Affidavit To affirm a domestic partnership for benefits purposes

Member Services
The Episcopal Church Medical Trust
19 East 34th Street
New York, NY 10016

Personal Health Record To maintain and organize personal health records and information

Medical/Dental Change Form To change employee and/or billing information on individual health plans

The Episcopal Church Medical Trust
19 East 34th Street
New York, NY 10016

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