DENTAL/VISION/HEARING INSURANCE CLAIM FORM
Send completed claim form to:
Notice
to all parties completing this form: It
is
BAC Local 56 Welfare Fund fraudulent to fill out this form with information you
Carol Stream, IL
60188 and/or civil penalties can result from such acts.
NOTE: Please
attach your original itemized dental, vision or hearing bill to this form. Make sure the itemized bill includes the
following information: Physician’s name,
address and phone number; full name of Patient; place where service was
received; diagnosis, if any; description of service(s) received; date(s) of
treatment; charge for each treatment or surgical procedure; amount member paid
and date paid.
MEMBER INFORMATION: Member’s Date of Birth:___________________________
Name:__________________________________________Social Security #______-_____-_________
Address:____________________________________________________________________________
City State ZIP code
Home Telephone Number:(______)____________________
PATIENT INFORMATION: Patient’s Date of Birth:____________________________
Name:__________________________________________Social Security #______-_____-_________
Address:____________________________________________________________________________
City State ZIP code
***PAYMENT WILL BE MADE TO MEMBER ONLY – NOT TO THE
PROVIDER. SEE BELOW FOR THE
GUIDELINES.***
CLAIM INFORMATION:
Is claim for accidental injury? 1YES 1NO
Is this a Workers Compensation Claim? 1YES 1NO Date of
Accident:_______________________
Briefly describe
injury:_____________________________________________________________________
COMPLETE BELOW FOR NON-ACCIDENTAL INJURY OR ILLNESS:
Date First Treated:_________________ Briefly describe condition(s) for which
patient received these
services:________________________________________________________________________________
OTHER INSURANCE INFORMATION:
Are there any OTHER dental/vision/hearing benefits
available to you, your spouse, or your dependents from OTHER Group Insurance,
such as another employer, school, etc.?
1 YES (provide information below) 1NO
Policy Holder Name:________________________________________Social
Security #______-_____-________
Policy Holder is: 1Member 1Spouse 1Child 1OTHER(explain relationship)
Address:__________________________________________________________________________________
City State
ZIP code
Insurance Carrier
Name:____________________________________________ Policy #__________________
Address:__________________________________________________________________________________
Telephone Number:_(_____)____________________
RELEASE OF INFORMATION:
I certify that the above information is correct and that the bills
attached were incurred by the patient listed above. I authorize any medical professional,
hospital, medical or medically related facility, pharmacy, government agency,
insurance company, or other person or firm to provide BAC Local 56 Welfare
Fund, including copies or records, concerning advice, care or treatment
provided the patient above including, without limitation, information relating
to mental illness, use of drugs or alcohol, upon presentation of the original
copy of this signed authorization. I understand that BAC Local 56 Welfare Fund will use
such information for the purpose of evaluating a claim for insurance benefits
for services provided to the patient named above. I understand that any authorized
representative or I will receive a copy of this authorization upon
request. The authorization is valid from
the date signed for the duration of the claim.
SIGN HERE:______________________________________________ Date:____________
SIGNATURE OF MEMBER
----------------------------------------- SUBMIT
ABOVE FOR CLAIMS ------------------------------------------
INCOMPLETE CLAIM FORMS, INCLUDING INSUFFICIENT BILLING
INFORMATION WILL BE RETURNED TO THE MEMBER WITHOUT PAYMENT.
The
Dental/Vision/Hearing Reimbursement Benefit has been in effect for each insured
member and his/her family since
Under this
benefit, the member may submit PAID
dental, vision and/or hearing bills incurred by the member or the member’s
dependent(s) to BAC Local 56 Welfare Fund and be reimbursed for the cost of
those expenses up to the annual family
maximum. Insurance deductibles do not
have to be met in order to use this benefit.
The health care provider may not submit claims on your behalf -
they will be rejected. Unpaid bills will
also be rejected. Effective February
23, 2000, there is a $400 maximum paid per pair of eyeglass frames (not
including lenses).
The annual
family maximum is the single amount available to the member for all of the
member’s and the member’s dependents’ dental, vision and hearing expenses
incurred for the calendar year.
THE FAMILY ANNUAL MAXIMUMS ARE AS FOLLOWS:
Effective
2) Plan B coverage - $2,500.00
CLAIMS MUST BE SUBMITTED WITHIN
NINETY (90) DAYS AFTER THE END OF EACH PLAN YEAR (ON OR BEFORE MARCH
31). Example:
2006 claims will not be paid after
PLEASE SUBMIT PAID
DENTAL/VISION/HEARING CLAIMS TO:
BAC
LOCAL 56 WELFARE FUND OR,
FAX YOUR CLAIMS:
CAROL
Requests
for claim forms and inquiries regarding your claim(s) should be directed to
Local 56 Welfare Fund (630) 653-5930, ext. 2.
In answer to many questions: YES! - You may use photocopied claim
forms. Claim forms are also available on
the internet at www.bac56il.org NO! – claims forms do not have to be on
the same color paper that we print them on.
Please note:
only bills that indicate the provision of dental or vision or hearing
services and show that all amounts on the bill have been paid, along with
billing codes, and an explanation of services, will be considered for
reimbursement. In addition, only
dental/vision/hearing benefits, which are described in Section 213(d) of the
Internal Revenue Code of 1986 will be available for reimbursement. This
would exclude reimbursement for services that are performed primarily for
cosmetic reasons (including teeth whitening).
CORRECTIVE VISION SURGERY (LASIK,
LASEK, PRK) IS ALSO COVERED BY THE PLAN
EFFECTIVE