| To be eligible for this benefit,you must be currently insured by the
Health & Welfare plan of Local Union 373. You,or any member of your
immediate family is eligible for reimbursement for optical
charges,including examinations,prescription eyeglasses or contact lenses.
Dependants shall include your lawful spouse and dependent children up to
their 23rd birthday. You are eligible for a reimbursement of up to
$100.00 every two consecutive calendar years beginning with the odd
numbered years for yourself and an additional amount for each eligible
dependent. Benefits are not assignable. Payment will only be made to you.
This claim form must be completed fully, and a statement or reciept must
show: Name of patient;name of provider (Doctor, Optometrist, Optician);
the date the charges was incurred and that the charge was paid. Do not
submit cash register receipts or cancelled checks. They will be
returned. Each charge must be accompanied by a complete
form. Insured's Name ________________________________ SS# ___________________________ Address: _______________________________________________________________________ _______________________________________________________________________ Patient's Name ___________________________________________________________________ If dependent, relationship to member ___________________________________________________ This is a claim for reimbursement for: (check one) Examination ____________ Prescription Eyeglasses ____________ Contact Lenses ____________ Providers Name __________________________________________________________________ Providers Address: ________________________________________________________________ ________________________________________________________________ Phone Number ________________________ Date Of Service ______________________________ Charges ________________________ I, the undersigned declare that the above claim is for myself, or an eligible dependent member of my family, and authorize the Trustees of the Health & Welfare Plan of Local Union 373 to verify the claim as may be required. Date ________________________ Signed ______________________________________ |