Teachers Health Trust : Forms

Forms

Click on the category of form that applies to you (e.g. provider or member), and click on the download link to download the form you want.

Medical Claim Form

Dental Claim Form

Dependent Certification Form

Consent to Discuss/Disclose Personal Protected Health Information (PHI)

Coordination of Benefits

Medco Mail Order Form

Mail your prescription(s) along with your completed form to:
Medco
P.O. Box 650022
Dallas, TX 75265–0022

VSP Out–of–Network Reimbursement Form

Student Status Verification & Employee Certification*

Dependent No Longer Meets Student Status Requirements

Two CCSD Employee Enrollment Form*

Health Insurance Waiver

Health Improvement Benefit Form

Medco Prescription Reimbursement Form