Get NY NYSNA Welfare Plan Optical Form 2009-2024

Asonet. com NYSNA WELFARE PLAN FOR NYC EMPLOYED REGISTERED PROFESSIONAL NURSES OPTICAL FORM Effective 4/1/09 Optical Benefits available for Full-Time Nurses and their dependents and Part-Time Nurses Member Only once every 24 months. RETURN TO Administrative Services Only Inc* P. O. Box 9005 Department 136 Lynbrook NY 11563 1-888-692-7671 www. PATIENT INFORMATION REQUIRED ON CLAIMS FOR SPOUSES AND DEPENDENTS Patient Name Birth date MEMBER/EMPLOYEE Relationship to Member Full Time College Student Spouse Yes Child School No INFORMATION Member Name Street Address Social Security City State Member s School or Work Location Zip Telephone SPOUSE INFORMATION Spouse s Name Print Is spouse covered by another Benefits Plan YES Name Address Telephone of Spouses Employer Name of Benefit Plan ARE ANY OTHER OPTICAL BENEFITS AVAILABLE FOR THIS PATIENT PROVIDER NO YES IS THIS AN HMO PLAN EXAMINER Provider s Name Print License Taxpayer ID Zip Code IS THIS CLAIM THE RESULT OF Accident or Injury Occupational Injury Yes Certification of Examiner I have examined the above named patient and have found the following vision defects Signature of Examiner Exam Fee Date PROVIDER INFORMATION DISPENSER OF FRAMES AND LENSES WAS THE EXAMINATION REQUIRED BY SERVICE AN EMPLOYER AS A CONDITION OF EMPLOYMENT FEE FRAMES LENSES Single Vision DATE BY A GOVERNMENT BODY FOR OFFICE USE You may check on eligibility for this benefit 24 hours a day 7 days a week by phone 516-396-5561 800-537-1238 ex 5561 or thru the internet Bifocal Trifocal Lenticular Only claims with a service date on or after 4/1/09 will be honored* Benefits are limited Contact Lenses to once every 24 months Signature of Dispenser AUTHORIZATION TO RELEASE INFORMATION I hereby authorize any insurance company prepayment organization hospital physician or its designated agent to release all information with respect to myself or any of my dependents which may have a bearing on the benefits payable under this or any other plan providing benefits or services. A photocopy of this authorization when duly executed shall serve in the same capacity as the original* I certify that the information submitted by me in support of this claim is true and correct. Authorization must be signed or payment will not be made. I understand that I am financially responsible for charges not payable by the Fund* Signed Patient or Parent if Minor ASSIGNMENT OF BENEFITS I hereby authorize payment of the benefits otherwise payable to me directly to the above named physician* I understand I am financially responsible for charges not covered by this authorization* Signed Member BENEFITS CANNOT BE ASSIGNED TO NON-PARTICIPATING PROVIDERS*. PATIENT INFORMATION REQUIRED ON CLAIMS FOR SPOUSES AND DEPENDENTS Patient Name Birth date MEMBER/EMPLOYEE Relationship to Member Full Time College Student Spouse Yes Child School No INFORMATION Member Name Street Address Social Security City State Member s School or Work Location Zip Telephone SPOUSE INFORMATION Spouse s Name Print Is spouse covered by another Benefits Plan YES Name Address Telephone of Spouses Employer Name of Benefit Plan ARE ANY OTHER OPTICAL BENEFITS AVAILABLE FOR THIS PATIENT PROVIDER NO YES IS THIS AN HMO PLAN EXAMINER Provider s Name Print License Taxpayer ID Zip Code IS THIS CLAIM THE RESULT OF Accident or Injury Occupational Injury Yes Certification of Examiner I have examined the above named patient and have found the following vision defects Signature of Examiner Exam Fee Date PROVIDER INFORMATION DISPENSER OF FRAMES AND LENSES WAS THE EXAMINATION REQUIRED BY SERVICE AN EMPLOYER AS A CONDITION OF EMPLOYMENT FEE FRAMES LENSES Single Vision DATE BY A GOVERNMENT BODY FOR OFFICE USE You may check on eligibility for this benefit 24 hours a day 7 days a week by phone 516-396-5561 800-537-1238 ex 5561 or thru the internet Bifocal Trifocal Lenticular Only claims with a service date on or after 4/1/09 will be honored* Benefits are limited Contact Lenses to once every 24 months Signature of Dispenser AUTHORIZATION TO RELEASE INFORMATION I hereby authorize any insurance company prepayment organization hospital physician or its designated agent to release all information with respect to myself or any of my dependents which may have a bearing on the benefits payable under this or any other plan providing benefits or services. A photocopy of this authorization when duly executed shall serve in the same capacity as the original* I certify that the information submitted by me in support of this claim is true and correct. .