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Forms & Publications

You can ask for a paper copy of your Summary of Benefits and Coverage (SBC) at any time, free of charge. Go to Forms and Publications. Check the box next to the Summary you want and then click on Mail It to Me. You can also call Client Services at (800) 480-9967 Monday - Friday 8:30AM to 8:00PM ET (excluding holidays) to request a copy.

The Medical Trust can also provide an SBC in a Spanish, Chinese, Tagalog, and Navaho. Please see our Notice of Nondiscrimination policy page or call Client Services for more information.

 

To request a copy by mail, check the box next to the title and click 

Retired Clergy Health Plan Information - 2018

  Title What is This For? Pgs
Medicare Supplement Handbook 2018 Handbook of plan details

126

N/A Retiree Open Enrollment (Subsidy) Letter 2018 Open Enrollment information for retirees who receive a subsidy

8

N/A Retiree Open Enrollment (Non-Subsidy) Letter 2018 Open Enrollment information for retirees who do not receive a subsidy

8

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To request a copy by mail, check the box next to the title and click 

Retired Clergy Health Plan Information - 2017

  Title What is This For? Pgs
N/A Your Healthy Retirement 2017 Non-Subsidy Health plan enrollment news for Episcopal Church retirees

6

N/A Your Healthy Retirement 2017 Subsidy Health plan enrollment news for Episcopal Church retirees

8

Medicare Supplement Handbook 2017 Plan Document Handbook

125

N/A Medicare Supplement Fact Sheet - Before July 1 2013 Retirement Medicare Supplement Fact Sheet - Retirement Before July 1, 2013

3

N/A Medicare Supplement Fact Sheet - After July 1 2013 Retirement Medicare Supplement Fact Sheet - Retirement After July 1, 2013

3

Prescription Drug Benefit Fact Sheet for Retirees 2017 The Medical Trust Pharmacy Benefit Fact Sheet for Retirees

4

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To request a copy by mail, check the box next to the title and click 

Popular 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

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

Express Scripts Home Delivery Order Form (Retirees) Express Scripts Home Delivery Order Form (Retirees)

EXPRESS SCRIPTS
PO BOX 66577
ST. LOUIS, MO 63166-6577

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

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

Hearing Benefit Reimbursement Claim Form Hearing Benefit Claim Form (UHC)

MAIL the Claim Form and the proof of payment attachments to:
UnitedHealthcare, Atlanta Service Center, PO Box 740827, Atlanta, GA 30374

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

Behavioral Health Out of Network Claim Form Member claim form

Cigna Behavioral Health, Inc.
Attn: Claims Service Dept.
P.O. Box 188022
Chattanooga, TN 37422

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

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

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

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To request a copy by mail, check the box next to the title and click 

Your Health Records

Title What is This For? Contact Information
Charting a Healthy Course Personal Health Record

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

Personal Medical Record Personal Medical Record

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To request a copy by mail, check the box next to the title and click 

Health News

  Title What is This For? Pgs
Health News, Spring 2017 Planting the Seeds for Your Tomorrow

1

Health News, Winter 2017 Being SMART about the New Year

1

Health News, Fall 2016 Putting Your Fears in Perspective

3

Health News, July/Aug 2016 Finding Freedom Across Your Life

5

Health News, Spring 2016 Springing into Action: Check In, Check Out, Check-up

5

Health News, Summer 2015 Health & Wellness News - Summer 2015

3

Health News, Spring 2015 Health & Wellness News - Spring 2015

3

Health News, Winter 2015 Setting Up for Success in 2015

3

Health News, Summer 2014 Health and Wellness Spotlight

3

Health News, Fall 2014 Fall edition of Health & Wellness News

3

Health News, November 2013 Member Stories

1

Health News, July/August 2013 Healthy Living

3

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* Our online documents are available for immediate download and viewing using Adobe's FREE Acrobat Reader.

Health benefits are offered through plans maintained by Church Pension Group Services Corporation (doing business as The Episcopal Church Medical Trust), 19 East 34th Street, New York, NY 10016.

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