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<br /> <br /> Send claims to: City Clerk, City of Auburn <br /> 25 West Main Street <br /> Auburn, WA 98001 <br /> 253-931-3037 <br />LEOFF 1 MEDICAL CLAIM FOR PAYMENT FORM <br /> <br />PART 1: Retiree / Employee Information (Claimant) Fire Police Active Retired <br />NAME (Last and First) <br /> <br /> DATE OF BIRTH <br />MONTH DAY YEAR <br /> <br /> ADDRESS CITY STATE ZIP <br /> <br /> <br />IS THIS AN ADDRESS <br />CHANGE? <br /> <br />  YES  NO <br />TELEPHONE NUMBER <br /> <br /> <br /> <br />E-Mail: <br />PART 2: Description of Claim TOTAL BILL: AMOUNT SUBMITTED: <br />DESCRIBE ILLNESS OR INJURY: (use supplemental form if <br />needed) <br /> <br /> <br />WORK RELATED ILLNESS OR INJURY? <br />  YES  NO <br />IF YES, DID YOU OR WILL YOU NOTIFY YOUR SUPERVISOR? <br />  YES  NO <br />IF CLAIM IS DUE TO ACCIDENT STATE WHEN, WHERE AND <br />HOW THE ACCIDENT OCCURRED (use supplemental form if needed): <br /> <br /> <br /> <br /> <br />HAS PATIENT BEEN TREATED FOR THIS ILLNESS OR INJURY WITHIN THE PAST 12 MONTHS? <br /> <br />  YES  NO IF YES, DATE OF SERVICE: _________________ <br /> <br /> <br />INSURANCE EXPLANATION OF BENEFITS FORM ATTACHED: YES NO <br />IF YES, NAME AND ADDRESS OF ATTENDING PHYSICIAN <br /> <br /> <br /> <br /> <br />REFERRING PHYSICIAN IF APPLICABLE __________________________________________ <br /> <br /> <br />PART 3: Group Health Insurance ATTACH ALL RELEVANT INSURANCE EXPLANATION OF BENEFIT FORMS <br /> <br />ARE YOU OR ANY OF YOUR FAMILY MEMBERS COVERED BY MEDICAL <br />INSURANCE? <br /> YES  NO <br /> <br /> CHECK ONLY THOSE COVERED BY OTHER GROUP INSURANCE: <br /> <br /> SELF  SPOUSE DATE OF BIRTH ___________________________ <br /> <br /> <br />NAME AND ADDRESS OF OTHER INSURANCE CARRIER: <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />POLICY NUMBER: _______________________________________________________ <br /> <br />EFFECTIVE DATE: ________________________________________________________ <br />IS PATIENT ELIGIBLE FOR MEDICARE BENEFITS? ATTACH MEDICARE EXPLANATION OF BENEFITS FORM <br /> <br /> YES NO IF YES, ENTER DATE OF ELIGIBILTY:______________________________________________________ <br /> <br /> <br />SOCIAL SECURITY NUMBER: XXX – XX - _________ <br /> <br />PART 4: Complete for all claims <br /> <br /> <br />I hereby certify that the above statements are complete and accurate to the best of my knowledge. I expressly authorize any service provider who <br />has treated me to furnish my medical records to the City of Auburn LEOFF Board or its designee. I hereby consent to examination for by any other <br />medical professional that the Board may require. I understand that this consent it given only for the purpose of establishing my right to LEOFF-1 <br />benefits. <br /> <br /> <br /> <br /> <br />RETIREE (EMPLOYEE) SIGNATURE ____________________________________________________ DATE _____________________________________ <br /> <br /> <br />PART 5: Benefit Claim Authorization by LEOFF representative <br /> <br /> <br /> __________________________________________________________________________________ DATE ____________________________________________ <br />FIRE OR POLICE REPRESENTATIVE SIGNATURE <br />(Revised 10-02-12)