Forms & publications

Enrollment Forms         Other Documents and Forms        Notices

All forms are provided in PDF format unless otherwise noted. The free Adobe® Reader® software is required.

ENROLLMENT FORMS

MUST Enrollment Form - updated March 2008
Use this form to enroll new participants and their dependents in health, dental, and/or vision coverage, and to designate beneficiaries for the Basic life insurance included with the MUST medical benefit.

Click here to see a sample form with tips for completing each field.

Life Insurance Enrollment and Beneficiary Form
The Option 1 portion of the form is required for all participants in groups that offer Option 1 (employer-paid) life insurance. The Option 2 portion of the form is used only for participants who elect Option 2 (employee-paid) life insurance. Beneficiaries for Option 1 and Option 2 coverage are also designated or changed on this form.

MUST Change Form - updated March 2008
Use this form to report changes in name, address, or marital status; to terminate a dependent’s coverage; report a change from active to retiree status; or to change beneficiaries for the Basic life insurance included with the MUST medical benefit.  Remember, you must submit this form to your clerk or HR/payroll person.  Do not submit it directly to MUST.

MUST Termination Form - updated March 2008
Use this form to terminate coverage for employees/trustees. (To terminate a dependent’s coverage, use the MUST Change Form.)

Declaration of Adult Dependent Form
This form must be notarized and submitted to MUST to establish eligibility for a common-law spouse or adult partner. This form replaced the Common Law Marriage Affidavit effective July 1, 2006. (NOTE - Use the Dependent Child Verification Form for eligible adult-age children.)

Basic Plan Acknowledgement Form

Participants who have elected to enroll in the MUST Basic plan will be asked to sign this affidavit acknowledging that they understand the Basic plan's limitations.

High Deductible Health Plan (HDHP) Acknowledgement Form

Participants who have elected to enroll in the MUST HDHP plan will be asked to sign this affidavit acknowledging that they understand the HDHP plan's limitations.

Authorization to Release Information (HIPAA)
This form allows participants age 18 and older to allow claims information to be released to one or more designated persons.

Evidence of Insurability Form (Standard Life Insurance)
Use this form for life insurance late enrollees and for participants who wish to apply for life insurance amounts above the guaranteed-issue amount.

Group Health Statement Form, Page 1   Page 2
These forms are used for participants in new groups, or for late enrollees in existing groups.

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OTHER DOCUMENTS and FORMS

MUST Coordination of Benefits (COB) Questionnaire

This form is completed annually and is used to inform MUST of any other coverages that you or your dependents may have.

MUST Prescription Drug Coordination of Benefits Claim Form

Use this form to request reimbursement under MUST when you or your dependents have primary prescription drug covereage with another insurance plan or have a MUST secondary plan.

SB419 GUIDANCE Worksheet - effective July 1, 2008

This form gives guidance in regards to the tax implications that may be caused by Senate Bill 419.  Use the worksheet as guidance if this situation affects you.

Travel Reimbursement Form

Submit this form to receive reimbursement for travel expenses for the sole purpose of receiving medically necessary services that cannot be provided in Montana.

MUST "Frequently Needed Numbers" List

This handy sheet includes telephone numbers for various questions you might have about eligibility, claims, pharmacy benefits, and other issues.

Preventive Benefits Flyer for 2008-09

This flyer helps MUST participants understand the difference between preventive and medical claims, and provides an overview of the MUST preventive benefit package including new colon cancer screening benefits. The flyer is designed to be folded in half, booklet-style.

Retiree Brochure

If you currently have MUST health benefits and are thinking of retiring, this brochure is for you! It also answers some common questions from those who have both MUST and Medicare coverage.

Caremark Pharmacy Benefit Form

Clicking this link will display another page where you'll find links to Caremark forms and publications.

High Deductible Health Plan RX Claim Form

Use this form to submit prescription drug claims when covered under the HDHP.

Accident Questionnaire

This form may be used for injury claims to determine whether some of the costs can be paid with no deductible under the MUST accident benefit.

Sample Claim Explanation of Benefits (EOB) Form

This PDF document helps to explain the MUST EOB form that participants receive after a claim has been processed.

MUST Domestic & International Claim Form

Use this form to submit a claim to MUST when you have paid a provider up front for medical or preventive services.

MUST Health Fair Claim Form

Use this form to submit claims when you have attended a health fair and are seeking reimbursement.

County Health Department Claim Form - Microsoft Word version

or PDF version 

County health department staff can fill out this form and submit to MUST for payment after administering immunizations to MUST participants. (Form updated June 2007)

Long Term Disability (LTD) Claim Form

Use this form to claim long term disability ((LTD) benefits.

HSA Payroll Deduction Authorization Form
Enrollees in the HSA-qualified high deductible health plan may provide this form to his/her employer to authorize payroll deductions to fund a Health Savings Account.

District Quote Data Form (for MUST Representatives; updated Feb. 2007)
This document is used for groups who are not currently insured through MUST and are seeking a quote.

2008 Proposal Document (for MUST Representatives)
This Word document can be downloaded and customized when providing a quote to a group.

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NOTICES

HIPAA Notice
This notice is provided to newly enrolled participants to describe the privacy protections provided under HIPAA laws.

Women’s Health and Cancer Rights Notice

This notice is provided annually to participants to discuss certain benefits that are guaranteed under HIPAA laws.

COBRA Continuation Rights Notice
This notice is mailed to participants upon initial enrollment describing their right to continue coverage under COBRA if they lose eligibility for group coverage.

Foreign Travel Letter (sample)

If you plan to travel outside the U.S., call the Claims Administration office (800-437-8500) for guidance on seeking health care from foreign providers. They can mail you a letter that explains the requirements.

Links to documents available elsewhere on this site:

MUST Summary Plan Description document

MUST Benefit Summary

Kalispell Benefit Summary

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