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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:___________________