Claim For Optical Reimbursement Form PDF Details

In navigating the complexities of eye care benefits, understanding the District Council 37 Health & Security Plan's Claim for Direct Optical Reimbursement form is essential for eligible members and their dependents. This form, serving as a crucial navigational tool, is designed to streamline the process of claiming reimbursement for optical services including eye examinations, frames, and lenses. Members are reminded that to be eligible for reimbursement, claims must be filed within a 30-day window from the service date. Additionally, the plan offers a comprehensive optical benefit covering three types of services within a two-year period, but there’s a catch: all three services must be claimed simultaneously by each covered individual. Furthermore, the guidelines stipulate that the benefit cannot be divided between Optical Voucher and Direct Reimbursement options – a rule put in place to ensure fairness and efficiency in the claim process. The form itself meticulously details the need for clear employee information, alongside required data regarding the optical services received – from the type of service to the provider’s details. For members, understanding each segment of this form, from employee to provider information, is critical to ensuring the timely and successful processing of their claims, safeguarding their right to optical health benefits.

QuestionAnswer
Form NameClaim For Optical Reimbursement Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdc 37 vision voucher, optical reimbursement form, optical voucher, dc37 voucher request form

Form Preview Example

DISTRICT COUNCIL 37 HEALTH & SECURITY PLAN

125 BARCLAY STREET, NEW YORK, N.Y. 10007 (212) 815-1234

CLAIM FOR DIRECT OPTICAL REIMBURSEMENT

PLEASE READ CAREFULLY: Claims filed later than 30 days from the date of service will be declared ineligible.

The Optical Benefit provides three types of services once in a two-year period for eligible members and their dependents: eye examination, and/or frames, and/or lenses.

THE TOTAL OPTICAL BENEFIT (ALL THREE TYPES OF SERVICES) MUST BE SUBMITTED AT THE SAME TIME BY EACH COVERED PERSON

(This rule applies to usage by an individual. It does not mean, for example, that all covered members in a family must use the benefit at one time.)

When submitting Direct Reimbursement, all three types of services must be listed on the same form. If only part of the benefit is obtained and submitted for Direct Reimbursement, the part not utilized at the time of the first submission cannot be submitted within the same two years.

The benefit cannot be split between the Optical Voucher and Direct Reimbursement.

THIS SECTION IS FOR EMPLOYEE INFORMATION. PLEASE PRINT CLEARLY.

Member’s Social Security No. or Personal ID No.

 

Last Name

 

First Name

 

 

 

 

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number and Street Address

 

 

 

 

 

 

Apt. No.

 

 

City & State

 

Zip Code

P

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

O

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Area Code) Business Phone

 

 

(Area Code) Home Phone

 

 

 

 

 

 

 

 

 

Y

 

 

 

 

 

 

 

 

 

 

 

 

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Department or Institution

 

 

 

 

 

 

Job Title

 

 

 

 

 

Date of Employment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P

 

 

 

 

First Name

 

 

 

 

 

 

 

Name of spouse/domestic partner’s employer

A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

T

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of spouse/domestic partner’s insurance carrier

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

 

 

 

EMPLOYEE

 

 

SPOUSE/DOMESTIC PARTNER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

T

 

 

 

CHILD

AGE ________

 

 

 

 

 

 

 

 

Member’s Signature

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THIS SECTION IS FOR PROVIDERS

 

 

 

 

 

 

 

 

 

SERVICES:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please complete the requested and applicable information:

 

 

 

 

 

 

 

 

 

P

 

 

 

 

 

 

 

 

 

 

 

Please

 

 

 

 

 

EXAMINER

 

 

 

 

 

 

 

TYPE OF SERVICE

 

 

 

Check

CHARGES

 

 

 

 

 

 

R

 

 

 

Eye Examination

 

 

 

 

 

 

$

 

 

 

 

Name ______________________________

 

O

 

 

 

Frames

 

 

 

 

 

 

$

 

 

 

 

Address ______________________________

 

V

 

 

 

Single Vision Lenses

 

 

 

 

 

 

$

 

 

 

 

Telephone No.______________________________

 

I

 

 

 

Bifocal Lenses

 

 

 

 

 

 

$

 

 

 

 

Date of Services ______________________________

 

D

 

 

 

Trifocal Lenses

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

E

 

 

 

Progressive Lenses

 

 

 

 

 

 

$

 

 

 

 

DISPENSER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

R

 

 

 

Contact Lenses

 

 

 

 

 

 

$

 

 

 

 

Name ______________________________

 

 

 

 

Cataract Single Vision Lenses over +8.00

 

$

 

 

 

 

Address ______________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cataract Bifocal Lenses over +8.00

 

$

 

 

 

 

Telephone No. ______________________________

 

 

 

 

 

 

Cataract Contact Lenses

 

 

 

$

 

 

 

 

Date of Services ______________________________

 

 

 

 

 

 

 

 

 

 

 

 

Total

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D C 3 7

FOR OFFICE USE ONLY DO NOT WRITE HERE

Claim No.

 

Amount

 

Claim Examiner

 

Date

Rev 02/10

How to Edit Claim For Optical Reimbursement Form Online for Free

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1. The optical voucher necessitates certain information to be entered. Make sure the next blank fields are complete:

Filling in part 1 of dc37 eye voucher

2. When this array of blanks is completed, proceed to enter the relevant information in these - P R O V I D E R, Bifocal Lenses, Trifocal Lenses, Progressive Lenses, Contact Lenses, Cataract Single Vision Lenses over, Cataract Bifocal Lenses over, Cataract Contact Lenses, Total, cid cid cid cid cid cid cid cid, CHARGES, EXAMINER Name Address Telephone, FOR OFFICE USE ONLY cid DO NOT, and Rev.

EXAMINER Name Address Telephone, cid cid cid cid cid cid cid cid, and Total of dc37 eye voucher

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