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+1 (718) 820-1690

Please select the appropriate form below. Forms can be filled out online, then downloaded or printed for submission.

Submit an Optical Claim — Patient Information Form

Fill in the fields below, then click Download Filled PDF. Your information is printed directly onto the official claim form. Print, sign, attach your original receipt, and mail.

IMPORTANT: Claims for purchases made prior to 120 days will NOT be paid. One form per patient.

Member Type

Active Member Retired Member

Part A — Patient & Insured Information

1. Patient's Name (First, Middle Initial, Last) *

2. Patient's Date of Birth *

3. Insured's Name (First, Middle Initial, Last) *

6. Insured's I.D. No. (include any letters) *

4. Patient's Address (Street, City, State, ZIP)

5. Patient's Sex

Male Female

8. Insured's Group No. / Group Name

7. Patient's Relationship to Insured

Self Spouse Child Other

10. Condition Related to Employment?

Yes No

11. Insured's Address (if different from patient)

9. Other Health Insurance Coverage

12. Authorization to Release Information — Signature

Date

13. Authorization to Pay Vision Care Benefits — Signature

Date

Your information is never sent to any server — the PDF is generated entirely in your browser.

Print, sign, attach original receipt and mail to:
New York City Electrical Division Health & Welfare Fund
P.O. Box 650479 · Fresh Meadows, NY 11365

Post Office Box 650479
Fresh Meadows, New York 11365
+1 (718) 820-1690
Info@local3ibewh.org

Mon - Fri: 9:00 AM - 5:00 PM
Sat & Sun: Closed
Closed Weekends and All City Holidays

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