Test Page – General Vision Services

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 *
SelfSpouse / Domestic PartnerDependentSpecial Coordination of Benefits (SCOB)

GENDER*
MaleFemale

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.*

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 mydependent, 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.

SCOB 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 *
SelfSpouse / Domestic PartnerDependentSpecial Coordination of Benefits (SCOB)

GENDER*
MaleFemale

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.*

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

Out of Network Claim Wellness

Member Information

Today's Date *

Date of Service *

Member's Name *

Member's Address *

City *

State *

Zip Code *

Member Phone *

DOB *

Patient Information

Patient Name *

DOB *

Patient Address *

City *

State *

Zip Code *

GENDER *

MaleFemale

RELATIONSHIP TO MEMBER *

SelfSpouse / Domestic PartnerDependent

Provider Information

Name of Business *

Phone *

Addess *

City *

State *

Zip Code *

Store's NPI

Doctor's NPI

Upload Store Receipt *

All receipts must be submitted together at the same time even if services and materials were purchased on different dates.

Out of Network Claim

Member Information

Today's Date *

Date of Service *

Email *

Benefit# *

Member's Name *

BSC# *

Member's Address *

City *

State *

Zip Code *

Member Phone *

DOB *

Patient Information

Patient Name *

DOB *

Patient Address *

City *

State *

Zip Code *

GENDER *

MaleFemale

RELATIONSHIP TO MEMBER *

SelfSpouse / Domestic PartnerDependentSpecial Coordination of Benefits (SCOB)

Full Name *

ID or SSN *

Provider Information

Name of Business *

Phone *

Address *

City *

State *

Zip Code *

Store's NPI

Doctor's NPI

Upload Store Receipt *

All receipts must be submitted together at the same time even if services and materials were purchased on different dates.

Survey Form

Direct Reimbursement Claim

Member Information

Patient Information

Out of Network Provider Information

SCOB Direct Reimbursement Claim

Member Information

Patient Information

Out of Network Provider Information

Out of Network Claim Wellness

Member Information

Patient Information

Provider Information

Out of Network Claim

Member Information

Patient Information

Provider Information

Zip Code From

CONTACT US:

Survey Form

Direct Reimbursement Claim

Member Information

Patient Information

Out of Network Provider Information

SCOB Direct Reimbursement Claim

Member Information

Patient Information

Out of Network Provider Information

Out of Network Claim Wellness

Member Information

Patient Information

Provider Information

Out of Network Claim

Member Information

Patient Information

Provider Information

Zip Code From

CONTACT US:

Lost Password