HomeMy WebLinkAboutLEOFF1 Medical Claim for Payment Form.pdf
Send claims to: City Clerk, City of Auburn
25 West Main Street
Auburn, WA 98001
253-931-3037
LEOFF 1 MEDICAL CLAIM FOR PAYMENT FORM
PART 1: Retiree / Employee Information (Claimant) Fire Police Active Retired
NAME (Last and First)
DATE OF BIRTH
MONTH DAY YEAR
ADDRESS CITY STATE ZIP
IS THIS AN ADDRESS
CHANGE?
YES NO
TELEPHONE NUMBER
E-Mail:
PART 2: Description of Claim TOTAL BILL: AMOUNT SUBMITTED:
DESCRIBE ILLNESS OR INJURY: (use supplemental form if
needed)
WORK RELATED ILLNESS OR INJURY?
YES NO
IF YES, DID YOU OR WILL YOU NOTIFY YOUR SUPERVISOR?
YES NO
IF CLAIM IS DUE TO ACCIDENT STATE WHEN, WHERE AND
HOW THE ACCIDENT OCCURRED (use supplemental form if needed):
HAS PATIENT BEEN TREATED FOR THIS ILLNESS OR INJURY WITHIN THE PAST 12 MONTHS?
YES NO IF YES, DATE OF SERVICE: _________________
INSURANCE EXPLANATION OF BENEFITS FORM ATTACHED: YES NO
IF YES, NAME AND ADDRESS OF ATTENDING PHYSICIAN
REFERRING PHYSICIAN IF APPLICABLE __________________________________________
PART 3: Group Health Insurance ATTACH ALL RELEVANT INSURANCE EXPLANATION OF BENEFIT FORMS
ARE YOU OR ANY OF YOUR FAMILY MEMBERS COVERED BY MEDICAL
INSURANCE?
YES NO
CHECK ONLY THOSE COVERED BY OTHER GROUP INSURANCE:
SELF SPOUSE DATE OF BIRTH ___________________________
NAME AND ADDRESS OF OTHER INSURANCE CARRIER:
POLICY NUMBER: _______________________________________________________
EFFECTIVE DATE: ________________________________________________________
IS PATIENT ELIGIBLE FOR MEDICARE BENEFITS? ATTACH MEDICARE EXPLANATION OF BENEFITS FORM
YES NO IF YES, ENTER DATE OF ELIGIBILTY:______________________________________________________
SOCIAL SECURITY NUMBER: XXX – XX - _________
PART 4: 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 for 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 _____________________________________
PART 5: Benefit Claim Authorization by LEOFF representative
__________________________________________________________________________________ DATE ____________________________________________
FIRE OR POLICE REPRESENTATIVE SIGNATURE
(Revised 10-02-12)
LEOFF 1 MEMBERS
CLAIM FOR PAYMENT INSTRUCTIONS
Part 1. Please complete as indicated.
Part 2. Please complete as indicated. The “total bill” means the total cost of services provided.
Amount submitted to LEOFF is the total bill minus any insurance or other payments eligible to be
received.
Part 3. R.C.W. 41.26.150 (2) reads, “The medical services payable under this section will be
reduced by an amount received or eligible to be received by the member under Workers’
Compensation, Social Security including the changes incorporated under Public Law 98-97 as now
or hereafter amended, insurance provided by another employer, other pension plan, or any other
similar source”. A City Attorney opinion interprets this to mean all LEOFF medical services payable
to a LEOFF 1 employee is secondary to all benefits which are available as noted above.
The LEOFF Board will require proof that all avenues of payment have been exhausted before
submittal to the Board for payment. NOTE: A COPY OF THE BILL AND ALL MEDICAL
INSURANCE EXPLANATION OF BENEFITS FORMS MUST ACCOMPANY YOUR CLAIM.
Part 4. Please sign and date the Claim Form and submit to your LEOFF Board representative at
25 West Main Street, Auburn, WA 98001. Include the required documentation for review and
processing.
Claim Processing Procedure: Submit your claim for reimbursement to your LEOFF
representative by the WEDNESDAY before the regularly scheduled LEOFF Board meeting (the first
Tuesday of each month) or mail you claim to the LEOFF Secretary, Auburn City Hall, 25 West Main
Street, Auburn, WA 98001. Any claim submitted after that day may be held until the next regularly
scheduled meeting. Claims which do not have complete documentation may be tabled by Board
action until the next LEOFF Board meeting; therefore, it is crucial to have the required paperwork
submitted with your claim.
Payment Procedure: If there are no irregularities and the Board approves your request for
reimbursement, your claim will be processed in the next regular vouchering period after the Board
meeting. The vouchers are issued to the LEOFF member.
All medical expenses are the LEOFF member’s responsibility to pay. Claim for necessary medical
services submitted to the Board shall be reimbursed to the member in the amount approved by the
Board.