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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.