Retiree Health Trust : Forms

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