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Optical Reimbursement Form

The document provides information about a direct optical reimbursement claim form for the District Council 37 Health & Security Plan. It states that claims must be submitted within 30 days of service. The optical benefit provides members with an eye exam, frames, and/or lenses once every two years. When submitting a claim, all services received within the two-year period must be listed on the same form at the same time. The benefit cannot be split between a voucher and direct reimbursement. The form collects information about the member, provider, and services received for reimbursement.

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635 views1 page

Optical Reimbursement Form

The document provides information about a direct optical reimbursement claim form for the District Council 37 Health & Security Plan. It states that claims must be submitted within 30 days of service. The optical benefit provides members with an eye exam, frames, and/or lenses once every two years. When submitting a claim, all services received within the two-year period must be listed on the same form at the same time. The benefit cannot be split between a voucher and direct reimbursement. The form collects information about the member, provider, and services received for reimbursement.

Uploaded by

olimazi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

DISTRICT COUNCIL 37 HEALTH & SECURITY PLAN

125 BARCLAY STREET, NEW YORK, N.Y. 10007 (212) 815-1234

CLAIM FOR DIRECT OPTICAL REIMBURSEMENT


PLEASE READ CAREFULLY: Claims filed later than 30 days from the date of service will be declared ineligible.
The Optical Benefit provides three types of services once in a two-year period for eligible members and their dependents: eye
examination, and/or frames, and/or lenses.
THE TOTAL OPTICAL BENEFIT (ALL THREE TYPES OF SERVICES) MUST BE SUBMITTED AT THE SAME TIME BY EACH COVERED PERSON
(This rule applies to usage by an individual. It does not mean, for example, that all covered members in a family must
use the benefit at one time.)
When submitting Direct Reimbursement, all three types of services must be listed on the same form. If only part of the
benefit is obtained and submitted for Direct Reimbursement, the part not utilized at the time of the first submission
cannot be submitted within the same two years.
The benefit cannot be split between the Optical Voucher and Direct Reimbursement.

THIS SECTION IS FOR EMPLOYEE INFORMATION. PLEASE PRINT CLEARLY.


Member’s Social Security No. or Personal ID No. Last Name First Name

E
M
Number and Street Address Apt. No. City & State Zip Code
P
L
O
Y (Area Code) Business Phone (Area Code) Home Phone
E
E
Department or Institution Job Title Date of Employment

P First Name Name of spouse/domestic partner’s employer


A
T
Name of spouse/domestic partner’s insurance carrier
I
E EMPLOYEE SPOUSE/DOMESTIC PARTNER
N
T CHILD AGE ________
Member’s Signature Date

THIS SECTION IS FOR PROVIDERS


SERVICES:
Please complete the requested and applicable information:
Please
P TYPE OF SERVICE Check CHARGES EXAMINER
R Eye Examination □ $ Name ______________________________
O Frames □ $ Address ______________________________
V Single Vision Lenses □ $ Telephone No.______________________________
I Bifocal Lenses □ $ Date of Services ______________________________
D Trifocal Lenses □ $
Progressive Lenses □ $ DISPENSER
E
Contact Lenses □ $ Name ______________________________
R
Cataract Single Vision Lenses over +8.00 □ $ Address ______________________________
Cataract Bifocal Lenses over +8.00 □ $ Telephone No. ______________________________
Cataract Contact Lenses □ $ Date of Services ______________________________
Total $
D FOR OFFICE USE ONLY ● DO NOT WRITE HERE
C
3
Claim No. Amount Claim Examiner Date
7

Rev 02/10

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