Statement of Claim for Optical Benefit IUOE 520

STATEMENT OF CLAIM FOR OPTICAL BENEFIT
Benefits of this plan are self-funded. Help control cost. Every dollar spent or saved directly affects each covered person.

If any information on this form is falsified you can and will be held liable for incurred charges.

Employers and Operating Engineers Local 520 Health & Welfare Fund Eight Executive Woods Court Swansea, IL 62226 (618)233-7978 Fax {618)233-7716
1. Member Name*

First NameLast Name
Member's Marital Status

SingleMarriedSeparatedWidowedDivorced
Spouses name (if married)

First NameLast Name
SS#*
Member Address*
Phone Number
3. Patient's Name
Relationship to Member
Birthdate

MonthDayYear
Date
Patient's Address
Patient's Phone Number
4. Is Patient employed? (check one)

YesNo
If YES, name of Employer
5. Is patient on Medicare? (check one)

YesNo
6. Is claim due to accident or employment (check one)

YesNo
If YES, give details
The Health and Welfare Fund is not responsible for work related injuries.
7. If married, is member's spouse employed (check one)

YesNo
If YES, Employers Name
8. Is patient covered for benefits by any other Optical Insurance Plan? (check one)

YesNo
If YES: Plan Name
Plan ID#
Address and Phone Number
Effective date of Coverage
Authorization to release information: I hereby authorize my Employer, Union, Employers and Operating Engineers Local 520 Health and Welfare Fund, or other companies or organization providing benefits or services for optical/medical treatment or supplies to release or obtain any information necessary to determine the benefits payable under the Employers and Operating Engineers Local 520 Health and Welfare Fund.
Signed (Member/Patient or Parent)

Clear
Date
Authorization to pay benefits to Physician or provider: I hereby authorize payment directly to the Provider of Optical and/or Medical Benefits for services, but not to exceed the reasonable and customary charge for those services.
Signed (Member)

Clear
Date
Attach the itemized list of charges if not previously sent by the Optical Provider
Should be Empty:

STATEMENT OF CLAIM FOR OPTICAL BENEFIT