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Get MD Vision Care Claim Form 2008

THE NATIONAL ASBESTOS WORKERS MEDICAL FUND VISION CARE CLAIM FORM 7130 Columbia Gateway Drive Suite A Columbia Maryland 21046 TELEPHONE 800-386-3632 410-872-9500 THE BENEFIT ALLOWANCE WILL BE PAID TO THE EMPLOYEE ONLY Print Employee Name Address Soc. Sec. No. Has Program Been Used Before City DYes o No State Zip Company Employed By Any other insurance coverage Telephone Number If yes name of insured TO BE SIGNED BY EMPLOYEE The undersigned employee certifies that the above information is true and correct and the below services and materials were rendered and supplied as indicated. The undersigned also agrees to pay the doctor for the below services and materials. I hereby authorize the doctor to release the information requested on this form* Signature of Employee Date Sunglasses not provided except in lieu of regular prescription glasses if eligible for same. Broken glasses or frames not covered unless participant eligible for benefits again and then in lieu of new glasses. Benefit Maximum 200 per calendar year for professional fees materials lenses and frames. Fees and lenses available once each calendar year - Frames only every other calendar year. TO BE COMPLETED BY DOCTOR COMPLETE APPROPRIATE ITEMS BELOW EXAMINATION FEE OPHTHALMIC MATERIALS PATIENT NAME AGE SINGLE or MULTI-VISION LENSES DATE OF EXAMINATION Address of Doctor Signalure of Doctor City Slale and Zip 500 - 1/08 52337 Type or Prinl Name and Fed* Tax 10 No*. I hereby authorize the doctor to release the information requested on this form* Signature of Employee Date Sunglasses not provided except in lieu of regular prescription glasses if eligible for same. Broken glasses or frames not covered unless participant eligible for benefits again and then in lieu of new glasses. Broken glasses or frames not covered unless participant eligible for benefits again and then in lieu of new glasses. Benefit Maximum 200 per calendar year for professional fees materials lenses and frames. Fees and lenses available once each calendar year - Frames only every other calendar year. Benefit Maximum 200 per calendar year for professional fees materials lenses and frames. Fees and lenses available once each calendar year - Frames only every other calendar year. TO BE COMPLETED BY DOCTOR COMPLETE APPROPRIATE ITEMS BELOW EXAMINATION FEE OPHTHALMIC MATERIALS PATIENT NAME AGE SINGLE or MULTI-VISION LENSES DATE OF EXAMINATION Address of Doctor Signalure of Doctor City Slale and Zip 500 - 1/08 52337 Type or Prinl Name and Fed* Tax 10 No*. I hereby authorize the doctor to release the information requested on this form* Signature of Employee Date Sunglasses not provided except in lieu of regular prescription glasses if eligible for same. Broken glasses or frames not covered unless participant eligible for benefits again and then in lieu of new glasses. Benefit Maximum 200 per calendar year for professional fees materials lenses and frames. Fees and lenses available once each calendar year - Frames only every other calendar year. .

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