Form Md 35 1 PDF Details

Facing a surgical procedure can be a daunting experience not only health-wise but also financially. This is where the MD-35-1 form enters the picture, serving as a beacon of support for those in need. Specifically designed for members of the UFA/UFOA Surgical Assistance Fund, this form encapsulates the process through which retired members, their widows, or dependents can apply for financial relief to cover surgical expenses. Located at the heart of Brooklyn, N.Y., at 9 METROTECH CENTER, the fund requires applicants to provide detailed personal, medical, and surgical information—from names to social security numbers, contact details, and the intricate specifics of the operation. This document underscores the importance of including supporting medical documents to validate the claim, while also setting clear boundaries on eligibility and the type of expenses covered. Exclusions are straightforward, with anesthesia and services of anesthesiologists not being covered, and a stern rule that claims older than a year will not be entertained. Moreover, it iterates the qualification criteria for dependent children, stressing the age limit and student status. Through this procedural gateway, the form seeks to offer a structured pathway for fund beneficiaries to receive the much-needed financial assistance during challenging times, provided they meet the fund's clearly outlined criteria.

QuestionAnswer
Form NameForm Md 35 1
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namessurgical assistance fund form, ufa md35, surgical assistance md 35, fdny fund form

Form Preview Example

UFA/UFOA Surgical Assistance Fund

MD-35-1 (11/97) 109-991518-190

9 METROTECH CENTER BROOKLYN, N.Y. 11201-3857

APPLICATION FOR BENEFIT IN SURGICAL ASSISTANCE FUND

DATE _________________

Retired ( )

Widow ( ) Name _____________________________________________Social Security No.______________________

Address: _________________________________________________________Telephone No: _____________________

TownState Zip Code

Rank: ___________________ Unit No. ____________________ Div. __________ Date Retired ____________________

Name of Patient ___________________________________________Age of Patient __________ Years

Relationship to Member ______________________________________ If child, give Date of Birth _________________

Name of Doctor ____________________________________________________________________________________

Office Address ________________________________________________________________Zip __________________

Name of Hospital ___________________________________________________________________________________

Address: _____________________________________________________________________Zip __________________

Doctor Used: HIP _______________ GHI _______________ Private ______________ Others _______________

Date/Dates of Operation: _____________________________________________________________________________

One of the following must accompany this claim:

An Official Medical Document, such as a Hospital Operation Report. MD-48, GHI bill, Anesthesia bill, a statement from the Doctor, etc., that states the name of the patient, diagnosis, full nature of the procedure and the date the procedure was performed. (Coded medical evidence cannot be used by this office)

NOTE: Receipt of claims will only be acknowledged when claimant encloses a stamped, self-addressed post card with claim.

ANESTHESIA AND/OR SERVICES OF ANESTHESIOLOGISTS ARE NOT COVERED BY THE FUND. CLAIMS 1 YEAR OR OLDER WILL NOT BE CONSIDERED UNDER ANY CIRCUMSTANCES.

ONLY DEPENDENT CHILDREN UNDER 19 YEARS OF AGE (INCLUDING FULL TIME STUDENTS) ARE ELIGIBLE FOR BENEFITS.

X ___________________________

(SIGNATURE OF MEMBER)

-------------------------------------------------------DO NOT FILL IN BELOW--------------------------------------------------------

(For S.A.F. Use Only)

Date of Entrance in Fund _________________________ Benefits Received since June 30 ___________$ _____________

Case No. __________________________________________ Date ___________________________________________

Amount to be Paid by Fund ______________________________ Basic Fee Rate ________________________________

Amount Deducted from Basic Fee Rate _________________________Check No. ________________________________

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fund md35 writing process shown (portion 1)

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Filling in segment 2 in fund md35

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