Do You Need a Form?
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UMWA Health and Retirement Funds

Do You Need a Form?

The list of forms below includes two of the most common medical forms used by physicians, hospitals and other facilities. It also includes other forms, such as for eye exams, mail order prescription drugs and change of address. If you do not see the form you are looking for, please call the Funds' Call Center at: 1-800-291-1425


CMS 1500: Used for physician billing

UB04: Used for hospital, rehabilitation centers, surgery centers and clinic billing


CBF and 1992 Benefit Plan Form




Caremark Claim Form

Mail Order Prescription Form

Preferred Product Program Exception

Brand Over Generic Medical Necessity Form


Authorization for the Use and Disclosure of Protected Health Information