Get NY MVFT Claim Form

RETURN TO SIDS Department 6-O PO Box 9005 Lynbrook NY 11563 516 396-5544 / 718 204-7172 www. asonet. com M MOUNT VERNON FEDERATION OF TEACHERS WELFARE FUND OPTICAL REIMBURSEMENT T V CLAIM FORM PATIENT INFORMATION REQUIRED ON CLAIMS FOR SPOUSES AND DEPENDENTS Patient Name Birth date Full Time College Student Spouse MEMBER/EMPLOYEE Relationship to Member Yes Child School No INFORMATION Member Name Social Security X X X-XXStreet Address 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 Street Address 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 Fee Date PROVIDER INFORMATION DISPENSER OF FRAMES AND LENSES SERVICE FEE DATE FRAMES LENSES Single Vision Bifocal Trifocal Lenticular Subnormal Contact Lenses Signature of Dispenser FOR OFFICE USE Note Limited to 150 per covered individual per calendar year with an additional 50. 00 paid toward either progressive or transition lenses OR an additional 25. 00 paid toward contact lenses. Refer to the benefit booklet published by the Fund for a complete description* This form when completed is to be mailed WITH AN ORIGINAL RECEIPT MARKED PAID within 90 days of the date you received the services listed. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR FUND FILES A STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME* AUTHORIZATION TO RELEASE INFORMATION I hereby authorize any insurance company prepayment organization hospital physician or The Board of Trustees of the Mount Vernon Federation of Teachers Welfare Fund 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. 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*. com M MOUNT VERNON FEDERATION OF TEACHERS WELFARE FUND OPTICAL REIMBURSEMENT T V CLAIM FORM PATIENT INFORMATION REQUIRED ON CLAIMS FOR SPOUSES AND DEPENDENTS Patient Name Birth date Full Time College Student Spouse MEMBER/EMPLOYEE Relationship to Member Yes Child School No INFORMATION Member Name Social Security X X X-XXStreet Address 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 Street Address 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 Fee Date PROVIDER INFORMATION DISPENSER OF FRAMES AND LENSES SERVICE FEE DATE FRAMES LENSES Single Vision Bifocal Trifocal Lenticular Subnormal Contact Lenses Signature of Dispenser FOR OFFICE USE Note Limited to 150 per covered individual per calendar year with an additional 50. 00 paid toward either progressive or transition lenses OR an additional 25. 00 paid toward contact lenses.