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City of Auburn LEOFF Board <br />Eye Examination, Corrective Lenses and Frames <br />WORKSHEET <br /> <br />ACTIVE MEMBERS <br /> <br />Vision insurance coverage is provided for active duty LEOFF 1 members through Vision <br />Service Plan. Please complete the information below and attach receipts and explanation of <br />benefits statements. The LEOFF Board will reimburse up to $270.00 per year for lenses and <br />frames (see LEOFF Policy 9.02). The reimbursement rate applies after all insurance <br />coverage’s have been applied. Any balance due after the LEOFF Board reimbursement is the <br />responsibility of the LEOFF 1 member. <br /> <br />NAME: _______________________________________________________________ <br /> <br /> <br />ADDRESS: ___________________________________________________________ <br /> <br /> Fire Police Active Retired <br /> <br /> Amount Paid by <br /> Billed Amount Insurance Balance <br /> <br />Eye Examination <br /> <br />$ <br /> <br />$ <br /> <br />$ <br />Type of Lenses: <br /> Single <br /> Bifocal <br /> <br /> Trifocal <br /> <br /> Progressive <br /> <br />Lenses <br /> <br />$ <br /> <br />$ <br /> <br />$ <br /> <br />Frames <br /> <br />$ <br /> <br />$ <br /> <br />$ <br /> <br />Contacts <br /> <br />$ <br /> <br />$ <br /> <br />$ <br /> <br />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 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 /> <br />LEOFF REPRESENTATIVE:__________________________________________ DATE:___________________