Read AFL-CIO- Out-Of-Network Claim Form.xls text version

AFL-CIO Health & Welfare Plan SPECTERA VISION CARE REIMBURSEMENT REQUEST FORM FOR OUT OF NETWORK SERVICES ONLY PART I - EMPLOYEE DATA Employee's Name Address Patient's Name Relationship To Employee City Social Security # State Zip Code Patient's Date of Birth Date

PART II - REQUEST

To obtain reimbursement, complete this form and submit this with your itemized bill and paid receipts to :

SPECTERA CLAIMS DEPARTMENT P.O. BOX 30978 SALT LAKE CITY, UT 84130 FAX: (248) 733-6060 I hereby request reimbursement for up to a maximum of $300 total for all services and materials below: Eye Exam Frames Contact Lenses (Necessary) Contact Lenses (Elective) Single Lenses Bifocal Lenses Trifocal Lenses Lenticular Lenses

Note: Receipts must be submitted together for services or materials purchased on different dates to receive reimbursement. Attach an itemized statement and paid receipt for your expenses. A separate claim form must be submitted for each patient. Contact lens reimbursements are in lieu of eyeglass lenses and frames.

Employee's Signature

Date

Spectera Customer Service: 1-800-638-3120

Information

AFL-CIO- Out-Of-Network Claim Form.xls

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