Direct Reimbursement Claim

Member Information

Today's Date *

Enter one: UFT Member ID, Welfare Fund ID or last 5 of SSN*

Name *

Email*

Address *

City *

State *

Zip Code *

Phone *

DOB *

Patient Information

RELATIONSHIP TO MEMBER *

Self Spouse / Domestic Partner Dependent Special Coordination of Benefits (SCOB)

GENDER*

Male Female

Name *

DOB*

Date of Service *

Address *

City *

State *

Zip Code *

Out of Network Provider Information

Name of Business*

Phone *

Address *

City *

State *

Zip Code*

Upload Store Receipt along with a copy of your eye exam RX
Please ensure your receipt image is clear and the text is readable, otherwise your claim may be delayed or denied.*

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To the best of my knowledge, the above information is true and correct and I or my dependent have received the service indicated above. In the event I receive an overpayment of benefits on my behalf or on behalf of my dependent, I am obligated to refund said overpayment to the Fund immediately.

No direct reimbursement will be made if service is rendered at a participating provider.