HomeMy WebLinkAboutLEOFF Vision Claim for Payment form.pdfCity of Auburn LEOFF Board
Eye Examination, Corrective Lenses and Frames
WORKSHEET
ACTIVE MEMBERS
Vision insurance coverage is provided for active duty LEOFF 1 members through Vision
Service Plan. Please complete the information below and attach receipts and explanation of
benefits statements. The LEOFF Board will reimburse up to $270.00 per year for lenses and
frames (see LEOFF Policy 9.02). The reimbursement rate applies after all insurance
coverage’s have been applied. Any balance due after the LEOFF Board reimbursement is the
responsibility of the LEOFF 1 member.
NAME: _______________________________________________________________
ADDRESS: ___________________________________________________________
Fire Police Active Retired
Amount Paid by
Billed Amount Insurance Balance
Eye Examination
$
$
$
Type of Lenses:
Single
Bifocal
Trifocal
Progressive
Lenses
$
$
$
Frames
$
$
$
Contacts
$
$
$
Complete for all claims
I hereby certify that the above statements are complete and accurate to the best of my knowledge. I expressly authorize any service provider who
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
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
benefits.
RETIREE (EMPLOYEE) SIGNATURE:__________________________________ DATE:___________________
LEOFF REPRESENTATIVE:__________________________________________ DATE:___________________